Endocrine Abstracts

Introduction: Thyroid Storm is a life-threatening but rare (incidence 0.2 per 100 000) disease state which presents as an extreme form of thyrotoxicosis. A hyper-metabolic state resulting from excessive thyroid hormone release which can be precipitated by both thyroidal and non-thyroidal illness.

Case: In this case we discuss a 72 year old female with previously treated Graves disease who presented in thyroid storm one week after annual flu vaccination. On initial presentation, she was in overt heart failure with bilateral pleural effusions and a community acquired pneumonia, atrial fibrillation at a rate of 170 beats per minute and acute confusion with significant agitation. The decision to treat initially with beta blockers was complicated by her being in heart failure with significant pulmonary oedema and a rapid ventricular rate precipitating a peri-arrest state. The guidance of the cardiologists to give amiodarone to chemically cardiovert conflicted with her thyrotoxic state. Relevant Data includes a Thyroid stimulating hormone of <0.05 mIU/l and a T4 of 96.5 pmol/l. A biochemically euthyroid state was eventually achieved using propathyaurocil, intravenous hydrocortisone, Lugols Iodine and Bile salts. Beta blockers and amiodarone were used with caution in the context of heart failure/suspected thyrotoxic cardiomyopathy and a thyrotoxic state respectively. Further investigation showed the patient had previously been treated for Graves and this was a late presentation recurrence seven years after completing block and replace therapy.

Discussion: We present this case because it highlights a rare case of thyroid storm presenting seven years following initial block and replace therapy had discontinued. The temporal relationship between presentation and the administration of the flu vaccination mean this must be considered as a potential non-thyroidal precipitant. The presentation in fast atrial fibrillation is also significant as the treatment of choice was amiodarone and this could have potentially exacerbated her underlying thyrotoxicosis.