PSAT316 Thyroid Storm Triggered by Coronavirus Disease-19 (COVID-19) In a Patient With Graves’ Disease

BACKGROUND: COVID-19 infection affects multiple organ systems including the endocrine system. Its effect on thyroid function has been reported in multiple studies and one of them observed overt thyrotoxicosis in 10.8% of COVID-19 hospitalized patients associated with higher mortality and longer hospital stays. There is paucity of data on the impact of COVID-19 in patients with pre-existing hyperthyroidism, with only few case reports highlighting the clinical course of such patients. We report a young woman diagnosed with Graves’ disease (GD) who was admitted 4 weeks later with thyroid storm precipitated by COVID-19. CASE: An 18 year old woman presented to the Emergency Room (ER) with fatigue, palpitations, diaphoresis, and diarrhea for 2 weeks. She had sinus tachycardia with heart rate (HR) of 118 beats per minute (bpm). She had diffuse thyromegaly and fine tremors on exam. TSH was < 0.01 uIU/mL and free Thyroxine (FT4) >8 ng/dL. Thyroid Stimulating Immunoglobulin (TSI) was elevated consistent with GD. She was admitted and treated with intravenous fluids (IV), propranolol and methimazole with significant improvement. She was discharged on methimazole and propranolol. FT4 improved to 3.31 ng/dL 3 weeks later with 100% medication compliance. A week later, patient visited ER due to sore throat, left earache, and dry cough. Influenza PCR and COVID-19 nasal antigen tests were negative, and patient was discharged on amoxicillin-clavulanate for suspected otitis media and acute pharyngitis. Her symptoms worsened over the next few days and she was admitted again with nausea, vomiting, anxiety, palpitations, dyspnea and diarrhea. She was febrile to 101F, HR 135 bpm with agitation and reduced concentration. Burch-Wartofsky score was 65, highly suggestive of thyroid storm. FT4 was elevated at 4.46 ng/dL. COVID-19 PCR was positive. She was treated with propylthiouracil, propranolol and IV hydrocortisone with gradual improvement in symptoms. She was discharged on methimazole, propranolol and prednisone 10 mg for 10 days. Due to worsening hyperthyroid symptoms and rise in FT4, 1 week after stopping prednisone, it was restarted, and an urgent out-patient surgical referral was placed. She was advised to repeat thyroid labs in 1 week. CONCLUSION: Thyroid storm is a rare, life-threatening endocrine emergency with a mortality rate of 10-30% that demands prompt recognition and timely intervention. Our case highlights that there must be a high index of suspicion for COVID-19 with worsening hyperthyroidism in patients with GD who are compliant with anti-thyroid medication especially if they have upper or lower respiratory tract symptoms. Patients with GD should be closely monitored during COVID-19 infection for development of thyroid storm. Early initiation of steroids might be considered with worsening thyroid function despite normal respiratory status to counteract inflammatory thyroiditis. Further studies will be useful to see the effect of COVID-19 infection in patients with GD. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.