AN ALTERNATIVE ROUTE OF TREATMENT FOR REFRACTORY VASODILATORY SHOCK DUE TO THYROID STORM

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Thyroid storm is a rare life-threatening thyrotoxicosis accounting for 16.2% of hospital admissions involving hyperthyroidism. Mortalities rates in thyroid storm have been found to be between 8-25%. This case involves a patient in refractory vasodilatory shock from thyroid storm requiring rectal propylthiouracil (PTU) with rapid resolution of shock. CASE PRESENTATION: 54-year-old woman with history of thyrotoxicosis secondary to Grave's disease, persistent atrial fibrillation, heart failure with reduced ejection fraction, polysubstance abuse, presented initially with dyspnea and tachycardia, found to be in atrial fibrillation with rapid ventricular response and thyrotoxicosis. She reported not taking her home medications for two weeks prior to admission as well as using cocaine intermittently. Her Burch-Wartofsky score was 65, consistent with thyroid storm. She was initially started on oral cholestyramine, methimazole, propranolol, SSKI drops, and intravenous hydrocortisone. Within eight hours of her admission she decompensated requiring multiple vasopressors and transfer to intensive care. On hospital day three she was started on rectal propylthiouracil (PTU) due to a concern for inadequate oral absorption while on four high dose vasopressors. Within 24 hours of receiving rectal PTU she needed minimal norepinephrine to maintain a normal mean arterial pressure. Two weeks later she underwent an I-131 radioactive iodine ablation and was subsequently discharged home. DISCUSSION: Treatment of thyrotoxicosis involves blocking thyroid hormone synthesis, release, conversion of T4 to T3, and decreasing the systemic effects. Majority of therapies available require oral absorption and are not always readily available in intravenous formulations. A study by Jongjaroenprasert et al. reported the successful treatment of fifteen clinic patients with hyperthyroidism using rectal administration of PTU. Prior to this study administration of rectal PTU had been given ten times in the literature. A case report published in 2006 presented a patient with thyrotoxicosis complicated by a perforated gastric ulcer who was successfully treated with rectal PTU. Intravenous formulations of both PTU and methimazole are also potential possibilities to explore should oral options be inadequate, but these are not often available. If the patient presented in this case continued to deteriorate, or developed toxicities from PTU, she would have been started on therapeutic plasma exchange (TPE). While the therapy has limited evidence to support TPE in thyroid storm, American Society for Apheresis recommends initiating TPE if first or second line medical therapies fail within 24-48 hours of treatment. CONCLUSIONS: Rectal PTU is a practical alternative and can be safely administered in critically ill patients in refractory vasodilatory shock. REFERENCE #1: Galindo, R.J., et al., National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004-2013. Thyroid, 2019. 29(1): p. 36-43. REFERENCE #2: Jongjaroenprasert, W., et al., Rectal administration of propylthiouracil in hyperthyroid patients: comparison of suspension enema and suppository form. Thyroid, 2002. 12(7): p. 627-31. REFERENCE #3: Zweig, S.B., et al., Rectal administration of propylthiouracil in suppository form in patients with thyrotoxicosis and critical illness: case report and review of literature. Endocr Pract, 2006. 12(1): p. 43-7. DISCLOSURES: No relevant relationships by Hannah Leschorn, source=Web Response No relevant relationships by Seema tekwani, source=Web Response No relevant relationships by Amanda Wiggins, source=Web Response