Endocrine Abstracts

A 72-year-old male patient presented to the ER because of general weakness, myalgia, frequent paroxysms of atrial fibrillation, shortness of breath, and hoarseness. The symptoms persisted for two months, gradually worsening and causing him to lose weight. At some point, he noticed redness of the sclera and soreness of the eyeballs. Paroxysms of rapid atrial fibrillation have been known for more than 15 years, so he had amiodarone in therapy. His initial laboratory findings showed markedly elevated fT4 >100 pmol/l, fT3 36 pmol/l, and suppressed TSH <0.01 mIU/l. Thyroid antibodies were normal. Ultrasonography showed a diffusely altered thyroid with normal blood flow, and no nodular changes. Therapy was started with thiamazole 30 mg daily, propranolol 80 mg daily, and methilprednizolone 32 mg daily. Amiodarone was excluded from therapy. Two weeks later, fT4 was still significantly elevated, above 100 pmol/l. The thiamazole dose was increased to 60 mg per day, and two weeks after that, fT4 began to decrease, so the thiamazole dose was reduced to 30 mg per day. Two weeks after the dose reduction, he came to ER due to rapid atrial fibrillation. The fT4 level was again greater than 100 pmol/l, so the thiamazole dose was increased to 60 mg per day and lithium carbonate was added to the therapy, while the dose of methilprednosolone was gradually reduced in the meantime. Because the fT4 level was still extremely high 400 pmol/l after 1 week despite therapy, the patient was hospitalized and therapy was continued with thiamazole at a dose of 90 mg daily, lithium carbonate, parenteral corticosteroid, and supportive therapy. After 7 days, a decrease in fT4 level to 64 pmol/l is observed. As the gradual decline in thyroid hormones continued, the dose of lithium carbonate and parenteral corticosteroids was gradually reduced but continued with high doses of thiamazole of 90 mg per day. As the patient´s recovery was monitored by continued reduction of corticosteroids, lithium, and thiamazole, it was planned to perform thyroidectomy after complete physical recovery and achievement of euthyroidism. The patient was discharged for home treatment. Lithium carbonate was discontinued after 1 week, corticosteroid after 3 weeks, and thiamazole after 6 months of gradual reduction with achievement of euthyroidism. The patient recovered completely, so he refused thyroidectomy.

Conclusion: Thyroid storm due to amiodarone therapy.