A Case of Atypical Thyroid Storm Presentation With Subsequent DIC, Hypoglycemia, Kidney Failure and Shock Liver

Abstract

Background: Thyroid storm is a rare and life-threatening emergency requiring prompt intervention that is diagnosed based on a combination of clinical, physical and biochemical findings. Presented here is a case of thyroid storm which proved a diagnostic challenge due to its atypical presentation and whose management was further complicated by uncommon sequelae including DIC, hypoglycemia, kidney failure and shock liver. Clinical Case: A 37-year-old female with Graves’ disease presented to the Emergency Department with a chief complaint of facial swelling with concern for recent food allergy. Initial labs revealed elevated fT4 of 5.17 ng/dL (n 0.6-1.12 ng/dL) and suppressed TSH <0.01 uIU/mL (n 0.45-4.12 uIU/mL), but otherwise normal range BMP and CBC. While awaiting admission in the ED, she had normal cognition, stable vitals and scored 25 per Burch-Wartofsky scale. Given significant thyrotoxicosis and history of non-compliance with Graves’ treatment, patient was nevertheless empirically started on treatment for suspected thyroid storm in addition to treatment for possible allergic reaction. In the ED patient suddenly went into cardiac arrest with ROSC achieved after 2 rounds of CPR. Following ROSC, labs showed BG of 24 mg/dL (n<115 mg/dL), WBC to 24 thousand/mcL (n 4.0-10.5 thousand/mcL), lactate >10 mmol/L (n< 2mmol/L), D-dimer >20,000 ng/mL (n<500 ng/mL), AST 1869 U/L (n<52 U/L). Patient underwent a prolonged hospital course requiring treatment for hypoglycemia, shock liver, acute kidney injury, heart failure, atrial fibrillation, DIC and embolic CVA. Her initial shock liver improved and transitioned into a cholestatic picture, prompting a change in her thionamides from PTU to Methimazole, then back to PTU later on. Her multi-organ failure improved gradually over 3 weeks with mechanical ventilation, CRRT, blood transfusion, stress dose steroids and comprehensive critical care treatment. Patient was eventually discharged with close endocrine, ENT, cardiology, and neurology follow up. Conclusion: In diagnosing and treating this rare but life-threatening endocrine emergency, a strong clinical suspicion should not be detracted by an atypical presentation and prompt action is needed. It is vital to remember that this is first and foremost a clinical diagnosis that can be further supported with laboratory and physical findings. Furthermore, this case is an example of the extent of multi-organ failure that can result from thyroid storm.