Storm’s a Brewing

Intro: Thyroid storm is an often feared but overall rare complication of untreated hyperthyroidism. This severe presentation of thyrotoxicosis has multiple different treatment modalities with actual treatment directed by the patient’s clinical course. We present the case of a 34-year-old male who presents in thyroid storm. Case: A male presented to the emergency department in southern Arizona in July with complaint of dizziness and tachycardia after working outside in the sun all day. He was rehydrated with symptomatic improvement but had continued tachycardia. The patient refused admission and left the emergency department prior to his thyroid function tests resulting with a TSH of <0.02 and FT4 of 7.43. He had no apparent follow-up or further symptoms until he presented back to the emergency department approximately one year later at age 34. He presented the second time with shortness of breath and palpitations and was found to have atrial fibrillation with rapid ventricular rate >200, a TSH <0.02, and TSH of 6.59. He was tachypneic, but his temperature and blood pressure were within normal limits. He had a CTA of the chest that showed bilateral pulmonary infiltrates. He was started on intravenous metoprolol and diltiazem without resolution of his tachycardia, so an amiodarone drip was started. Hours later, the patient became hemodynamically unstable and went into cardiac arrest. Return of spontaneous circulation was obtained and the patient was intubated with post-arrest cooling protocol initiated. The patient was clinically diagnosed with thyroid storm, which was supported by an elevated Burch-Wartofsky score. Post-arrest treatment of thyroid storm was complicated by acute liver failure, systolic heart failure with ejection fraction <20%, and persistent tachycardia. The patient was treated with high dose methimazole, propranolol, potassium iodine drops, corticosteroids, and cholestyramine. Surgery was considered given the slow progression of medical treatment but no pursued due to cardiovascular risk. Plasmapheresis was considered but not available. The patient’s thyroid function was followed daily and improved over a week despite persistent tachycardia and delirium. Eventually, the patient was discharged home with daily methimazole 20mg and planned outpatient follow-up for definitive therapy. Discussion: This patient presented to the ED with evidence of thyrotoxicosis that was untreated for one year prior to returning with thyroid storm. This illustrates the ability of a young, otherwise healthy patient to compensate for a prolonged period with relatively few symptoms prior to decompensating. This also shows the importance of having a system in place to catch abnormal laboratory results even if the patient is no longer present in the facility; a project has already been completed to catch abnormal thyroid function testing at our facility in the future.