FRI499 The Importance Of Identifying Atypical Presentation Of Thyroid Storm

Abstract

Abstract Disclosure: D.H. Sacoto: None. C.A. Villavicencio: None. A. Franco-Akel, MD: None. R. Belokovskaya: None. Thyroid storm is a rare and life-threatening syndrome. Despite treatment and supportive measures, it has an estimated mortality around 8–25%. Identifying atypical clinical presentation such as psychosis is crucial since prompt diagnosis and treatment is paramount for survival. We present an unusual case of psychosis as the manifesting symptom of thyroid storm.A 54-year-old female with a history of major depressive disorder, hypertension, and Graves’ disease presented to the ED with a 3-day history of bizarre behavior noted by the family. At the time of examination, the patient had pressured and circumferential speech, flight of ideas, labile mood, and paranoid ideations. On further questioning, patient reported palpitations and lack of sleep on days previous to presentation. Vital signs revealed hypertension (182/101 mmHg), tachycardia (176 beat per minute), tachypnea, and a temperature of 99.6 °F. Warm skin, fine tremors, and patellar hyperreflexia were noted on physical examination. Subsequent studies showed a suppressed TSH (<0.01uIU/mL), an elevated T3 (227ng/dL) and free T4 (2.1ng/dL). TSH receptor antibody was found positive. Patient’s clinical presentation combined with a Burch-Wartovsky scale of 55 stablished the diagnosis. Further history was notable for non-adherence to methimazole. Iodine-131 was administered. Further treatment with prednisone, propranolol, and cholestyramine was started. Patient showed subsequent clinical improvement. Thyroid storm is a rare complication of hyperthyroidism. It is commonly precipitated by infection, surgery, or medication non-adherence. Atypical presentation of thyroid storm can be disguised as psychiatric condition or substance abuse disorder. These manifestations can be the result of a generalized hypermetabolism generated by an increase in NA+/K+ ATPAse activity, raising the basal metabolism, resulting in thermogenesis. In addition, upregulation of beta-adrenergic receptors lead to increased central nervous system sympathetic response. This results in a catecholamine surge which may manifest as psychosis, mania, or coma. Being aware of atypical presentation in thyroid storm such as active psychosis is key in early diagnosis and prompt management. Presentation: Friday, June 16, 2023