Endocrine Abstracts

Thyroid storm is rare life-threatening clinical manifestation of endocrine dysfunction originating from excess level of thyroid hormone leading to hypermetabolic state with an incidence of 0.57-0.76/1000,000. The increase demand of metabolic activity subsequently induces, palpitations, dyspnoea, exercise intolerance and congestive heart failure. Most common cardiovascular manifestation of thyroid storm is tachycardia and atrial fibrillation occurs in up to 15% of patients. In very rare incidence ischemic stroke can co-occur with thyroid storm, whether it is precipitating factor or not is unclear. Without adequate treatment for both thyrotoxicosis and stroke mortality can be as high as 100%, therefore early recognition and management is essential. Herein we present a case of a patient with poorly controlled thyrotoxicosis leading to development of malignant left middle cerebral artery infarct. 58-year-old gentlemen admitted to emergency department with a sudden onset right sided weakness, facial drop, and aphasia with a NIHSS 23/42, His background is hyperthyroidism with poor compliance of medication, DVT, AF, and anaemia. On examination showed low GCS of 11 (E4V1M6), patient was able to track with eyes, no verbal response, with dense right sided weakness ongoing. CT head showed subtle hyperdensity of the left middle cerebral artery and loss of grey-white matter definition within the basal ganglia of the left cerebral hemisphere. Patient was thrombolysed and had thrombectomy, he then developed malignant MCA and underwent decompressive hemicraniectomy which led to an ITU admission where a tracheostomy was also performed. Patient was found to have thyrotoxic storm and was treated with lugols iodine, cholestyramine, iv hydrocortisone, propranolol and high dose propylthiouracil.

Discussion/Conclusion : Thyroid storm is a medical and an endocrine emergency that requires urgent management. Long standing and poorly managed thyroxicosis can cause thyrotoxicosis induced cardiomyopathy leading arrythmias including fast AF as well as heart failure. Fast AF can lead to ischaemic stroke with undesired outcome as demonstrated in this case report. This case highlights the importance of complying with the treatment for thyrotoxicosis as it can cause devastating consequences with severe life threating event with long term effect. In the light of this event, offering definitive treatment (in form of radioactive iodine or thyroidectomy) is vital in to avoid adverse or catastrophic outcome.

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