Endocrine Abstracts

Background: Thyroid storm is a rare but dangerous condition which can lead to multi-organ failure if not treated aggressively. Currently accepted treatment is with anti-thyroid medications to convert patients to a euthyroid state before definitive treatment with thyroidectomy is performed 10–14 days later. We present a case that was managed medically for several months due to a delay in surgery for clinical reasons. At present there are few such cases in the literature.

Case description: A 32-year old female presented to clinic with a 5 week history of tremor, palpitations, weight loss and sweating. She had no past medical history and was 2 weeks post-partum. Her pregnancy was uncomplicated apart from pre-eclampsia. On examination she was thyrotoxic and thyroid function tests (TFTs) showed TSH<0.02, T₃>50, T₄>100. She was diagnosed with Graves disease and started on carbimazole. A week later she presented with worsening symptoms and thyroid storm was diagnosed. ECG changes were consistent with an inferior myocardial infarction (troponin rise of 6527). A coronary angiogram showed right coronary artery dissection which was treated medically. An echocardiogram confirmed severe left ventricular diastolic function. She was admitted to intensive care for the treatment of thyroid storm with propylthiouracil, Lugols iodine and hydrocortisone. In contrast with current guidance a multi-disciplinary decision was made to delay thyroidectomy due to the myocardial insult. She was discharged and weekly TFTs over the next few months showed no disease progression. Her total thyroidectomy is planned for June 2015; 7 months post presentation, giving time for the myocardium to settle.

Conclusion: There is no data in the literature regarding the optimum time to perform a thyroidectomy in thyroid storm for patients with recent myocardial damage. This case highlights a unique situation where surgery was delayed and shows that thyroidectomy can be delayed safely in some high risk cases.