Endocrine Abstracts

Introduction: Thyroid storm presents as multiorgan dysfunction. Diagnosis is purely clinical, and early diagnosis improves the outcomes.

Case Presentation: 45-year-old lady without significant illness presented with breathlessness, productive cough, anxiety, and weight loss. Chest x-ray showed right pleural effusion and left consolidation. She was in fast AF with NT-proBNP >27000. initially treated as chest sepsis with CHF. Echo showed mild LVSD. TFT: TSH <0.01mu/l, FT4 44.4 pmol/l, FT3 23.5 pmol/l and TRAb 34.1 U/l. Graves’ ophthalmopathy present. BWPS 65 - thyroid storm. Admitted in ITU - carbimazole, beta-blocker, steroids, and inotropic support. US thyroid - diffuse enlargement with hypervascularity. CT-PA and CT abdomen-pelvis - acute PE, bilateral pleural effusion, gross ascites, generalised lymphadenopathy, and a pelvic mass. Search for intrabdominal malignancy - peritoneal cytology was negative for malignancy. CA-125 was raised (1861 Ku/l) - normalised later. MRI pelvis - large degenerated subserous fibroid with no ovarian mass (not struma ovarii). After ITU step down, she remained bed bound for many weeks due to proximal muscle weakness secondary to thyrotoxic proximal myopathy. She developed hypercalcemia (highest Calcium 3.04 and PTH 0.3) secondary to immobility +/- thyrotoxicosis. She developed necrotic lesions affecting her abdominal wall and lower limbs which was later found to be apixaban related leukocytoclastic vasculitis. These improved after apixaban being switched to rivaroxaban. Biopsy of the enlarged axillary lymph node was planned. However, they were found resolved at the planned biopsy date.

Discussion: AF and arterial/venous thrombosis are common. Other features include cardiomyopathy, cardiac/respiratory/renal failure, rhabdomyolysis, hepatic/haematologic/neurologic manifestations. Hypercalcaemia Generalised lymphadenopathy are reported in severe untreated Graves’. CA-125, a well-established marker of ovarian cancer, is an indicator of CHF, and a guide to decongestion therapy. Apixaban is a rare cause of leukocytoclastic vasculitis mandates switch to different agent, and immunosuppression(if skin necrosis).