SESSION TITLE: Critical Care Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Monday, October 27, 2014 at 11:00 AM - 12:00 PM
INTRODUCTION: Thyroid storm is a life-threatening complication of thyrotoxicosis characterized by tachycardia, hyperpyrexia, central nervous system dysfunction, and gastrointestinal symptoms. Multi-system organ failure is rare but accounts for the approximately 10% mortality of thyroid storm1.
CASE PRESENTATION: A 29 year old male presented to the emergency room complaining of abdominal distention and vitiligo. He was febrile (39.2 C) and in atrial fibrillation with rapid ventricular response (148 bpm). Thyroid stimulating hormone (TSH) was <0.01 uIU/mL (0.45-4.50 uIU/mL) and free T4 was >6.00 ng/dL (0.7-1.5 ng/dL). Thyroid stimulating antibody was 5.5 (<= 1.3) consistent with Grave’s disease. Initial management included metoprolol, propylthiouracil (PTU), and hydrocortisone. While in the ED, his mental status acutely declined and he became hemodynamically unstable. During the following 12 hours his transaminases rose from previously normal to AST 5265 U/L (<35 U/L) and ALT 2716 U/L (<55 U/L) with coagulopathy (INR 5.6). He developed acute renal failure (Cr 0.6 to 2.6 with oliguria) requiring continuous renal replacement therapy. Transthoracic echocardiogram revealed biventricular heart failure with right ventricle dilation and left ventricle ejection fraction 30-35%. This was confirmed by right heart catheterization (PCWP 25 mmHg, CI 1.9 L/min/m2).
DISCUSSION: Given the contraindication of methimazole and PTU in acute liver failure, an alternative strategy of plasma exchange followed by thyroidectomy was pursued. After plasma exchange on hospital day 1, free T3 declined from >30.0 to 14.3 pg/mL (2.3-4.2 pg/mL) and total T3 declined from 741 to 299 ng/dL (58-159 ng/dL) associated with improvement in vital signs and vasopressor requirement. Despite his critical illness and coagulopathy, he was taken for emergent thyroidectomy on hospital day 2. Post-operatively he had rapid decline in his circulating thyroid hormones associated with improved hemodynamics and liver enzymes. He required levothyroxine supplementation on hospital day 4. Currently the patient is improving with normalization of liver and cardiac function. Likewise, his mental status is improving and he is weaning from mechanical ventilation. He remains on renal replacement therapy as of this submission.
CONCLUSIONS: This case highlights a novel and multi-disciplinary approach of pharmacotherapy in conjunction with plasma exchange followed by thyroidectomy to successfully control severe thyrotoxicosis.
Reference #1: Thyroid. 2012 Sep;22(9):979.
DISCLOSURE: The following authors have nothing to disclose: Elaine Cagnina, Ramya Embar-Srinivasan, Sue Brown, Kyle Enfield
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