Endocrine Abstracts

Thyrotoxic storm is one of the rare but serious, and sometimes life threatening endocrine emergencies, the mortality rate ranges from 20 to 30%.

We report the case of a 44-year-old female who had an emergency hospital admission with diarrhoea, vomiting and palpitations in September, 2011. She was diagnosed with Graves thyrotoxicosis in 2004 and was commenced on carbimazole. She was non compliant with the treatment and did not attend her hospital appointments regularly. Her past medical history included anxiety, suspected anorexia nervosa in the teenage years and iron deficiency anaemia. Examination revealed bilateral basal crackles and peripheral oedema. Bloods confirmed thyrotoxicosis. The diagnosis of thyrotoxic storm with high output heart failure was made and she was treated with β blockers, propylthiouracil, IV steroids and Lugol’s Iodine. Few hours following the admission, she suffered asystolic cardiac arrest and was resuscitated successfully. During the ITU stay, her liver functions deteriorated significantly. It was thought to be either due to propylthiouracil or ischaemic hepatitis secondary to cardiac arrest. Propylthiouracil was swapped with carbimazole and liver functions improved slowly but steadily. On discharge, her thyroid and liver functions had stabilized on Carbimazole and she was referred to ENT team for the consideration of thyroidectomy.

This case poses clinical challenges at multiple steps. Continual non compliance was assumed to be the precipitating factor for the thyrotoxic decompensation. She was lost to follow up due to multiple non attendances and the impact the possible psychiatric history had on her condition was not evaluated further. Propythiouracil use in the acute illness could have contributed to the liver failure. Propylthiouracil is still being used in severe thyrotoxicosis due to its inhibitory effect on T₄ conversion to T₃. The 2009 FDA warning regarding propylthiouracil and hepatic failure should prompt revision of thyrotoxic storm management guidelines.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.