Endocrine Abstracts

Case History: 49 year old female presented to emergency with severe shortness of breath with non-productive cough, of 5 days duration. There was no h/o flu like symptoms nor GI symptoms. She did not have a significant past medical history but consumed alcohol in excess and was a heavy smoker. On examination, the patient was of normal build, with blood pressure of 150/90 mm Hg and pulse rate of 160/min, irregular. There were fine hand tremors, with sweaty palms and forearms. There was no proptosis, and no palpable goitre. Her respiratory examination revealed bibasal crackles and cardiovascular examination showed pan systolic murmur. Her abdominal and neurological examinations were normal. Her Burch Wartofsky scale for thyrotoxicosis was 65. Soon after admission, she was posted for CTPA to rule out pulmonary embolism for her acute shortness of breath. Patient deteriorated rapidly following CTPA and was intubated and transferred to ITU for ventilation and vasopressor support

Investigations: Her TSH was <0.001 with T3 – >30.4 pmol/l (2.9-4.9 pmol/l) & T4 >64 pmol/l (9-19 pmol/l) markedly elevated. Her anti TPO antibodies was positive and Anti-TSH Receptor antibodies level was 20.11 IU/l (0-2 IU/l). US Neck showed features suggestive of Grave’s disease. Her US abdomen showed portal venous flow demonstrated with marked pulsatility and distended hepatic veins suggestive of right-sided heart failure with ECHO showing features of elevated right atrio-ventricular pressures. Her CTPA was Negative for pulmonary embolus with appearances suggesting significantly raised right sided pressures and small right pleural effusion.

Results and Treatment: She was treated for multi organ failure due to possible potentiation of thyrotoxicosis by iodine based contrast. She received high dose carbimazole 30 mg once daily along with bisoprolol 10 mg once daily followed by fluids and vasopressors for treatment for heart failure. She recovered after prolonged intensive treatment and was stepped down to ward based care. On discharge, she had been followed in the endocrinology clinic and her TFT results improved with subsequent visit.

Conclusion & point of discussion: Iodine mediated contrast can aggravate or precipitate thyrotoxicosis in patients of hyperthyroidism especially Grave’s disease, multinodular goitre, and patients living in iodine deficient areas. This can precipitate life threatening complications such as arrhythmias, heart failure and venous thromboembolism. Iodinated contrast mediated acute deterioration of thyrotoxicosis due to Jode-Basedow effect is an important complication and judicious use of such investigations is essential.