Endocrine Abstracts

Introduction: Thyroid storm is a major life-threatening condition in a patient of thyrotoxicosis which can precipitate the cardiovascular morbidity in forms of tachycardia, arrythmia and congestive heart failure. It can be precipitated by acute coronary syndrome. Most literatures have reported acute coronary syndromes during the presentation itself but we describe an unique case where the diagnosis was possible after the resolution of the thyroid storm.

Clinical case: A 55-year-old graves’ disease patient had presented with classical features of thyroid storm which was precipitated by discontinuation of the anti-thyroid drugs. His initial electrocardiogram (ECG) showed sinus tachycardia. He was promptly started on intravenous fluid, 80 mg of daily carbimazole along with lugol’s iodine and intravenous dexamethasone. Within 48 h of treatment, his vitals became normal with resolution of the thyroid storm. His thyroid hormone status also showed marked improvement (free T4 falls from 90.31 ng/dl to 2.31 ng/dl) (normal range: 0.7 ng/dl-1.7 ng/dl). Due to his persistent jaw pain, mild chest discomfort and hiccough, ECG recordings were done in regular intervals. Interestingly it showed dynamic changes consisted of biphasic T waves. This ECG changes were seen after the resolution of the thyroid storm features. The cardiac enzymes were within normal limits. Wellen’s syndrome was suspected. Coronary angiography revealed left anterior descending artery (LAD) obstruction and patient promptly underwent percutaneous transluminal angioplasty. Patient’s angina equivalent symptoms had resolved remarkably. He recovered satisfactorily and was discharged after 5 days.

Clinical lesson: Ischemic heart disease is a well-known co-morbidity in a case of thyroid storm which can be identified at the initial presentation. But here the dynamic changes of ECG appeared after the resolution of the thyroid storm. It was classical of type A wellen’s wave which is a harbinger of imminent massive anterior myocardial wall infarction due to near-complete blockage of LAD. Initial sinus tachycardia probably had masked the appearance of typical Wellen’s wave in this case. But as soon as the thyroid storm resolved, typical dynamic changes appeared in the form of wellen’s wave. Early suspicion due to following serial dynamic ECG changes has prevented a major catastrophe in this case. This case highlights the importance of tracking serial ECG changes in a patient of thyroid storm which can unmask any underlying ischemic cardiac disease even after apparent improvement of the clinical status. This clinical case also reports a unique association of thyroid storm and type A wellen’s syndrome.