Endocrine Abstracts

Introduction: Thyroid storm is a rare endocrine emergency associated with the reported mortality rate ranging from 10 to 20%. We discussed the management of two cases of thyroid storm with different outcomes. It also showed the successful use of ECMO in the management of severe hyperthyroidism related cardiomyopathy and circulatory collapse.

Case History 1: A 36 years old female with known history of Graves’ disease, presented with palpitations and shortness of breath. She had pyrexia of 38 °C. She was in atrial fibrillation and acute left ventricular failure. Thyroid function tests showed TSH level of 0.01 mU/l, fT₄ level >100 pmol/l and fT3 level of 35 pmol/l, suggestive of clinical diagnosis of thyroid storm. The identified precipitating factors were non-compliance towards medication and job related stress. She was successfully managed in coronary care unit with standard medical therapy and was booked for definitive therapy with radioactive iodine.

Case History 2: Another 53 years old female with known Grave’s disease and poorly compliant to medical therapy also presented with shortness of breath and palpitations. She was quite unwell due to atrial fibrillation resulting in heart failure, renal failure and liver failure. Thyroid function tests were grossly deranged. Due to multi-organ dysfunction she was transferred to intensive care unit requiring invasive ventilatory support, and inotropic support. Medical and supportive therapy failed to stabilize her, prompting transfer to a regional centre for VA-ECMO support and requiring emergency thyroidectomy and tracheostomy. Her surgery was complicated by vocal cord paralysis needing long-term rehabilitation.

Discussion and learning points: • Early recognition, prompt level 1 and multi-disciplinary care can be crucial to reduce thyroid storm related mortality. • The ECMO can successfully be used in endocrine emergencies causing cardiorespiratory collapse due to reversible aetiology. • Potential consequences of poor compliance of patients of Graves’ disease towards medical therapy can help to delineate the importance of early definitive therapy.