FRI500 Atypical Case Of Undifferentiated Shock

Abstract

Abstract Disclosure: V. Vadini: None. P. Vasistha: None. Introduction: Shock is encountered frequently in the ICU. Undifferentiated shock, however, poses a diagnostic challenge. The differentials and work up are broad and time sensitive. Endocrinopathies are a known etiology but thyroid cardiomyopathy causing cardiogenic shock is rare. Clinical case: A 78 y old man presented to the ER with hypotension that did not improve after administration of 2.5 L IV fluids. Vasopressors were initiated and he was admitted to the ICU. Patient reported 2-month history of generalized weakness, nausea, vomiting, falls and poor oral intake. Review of systems was notable for 20-pound weight loss in 6 months, dyspnea with exertion, loss of appetite and occasional diarrhea. On exam, patient was afebrile, hypotensive 80/40, PR 87, O2 saturation > 90% on room air. He appeared pale with JVP measured at 11 cm of water. Pulse was irregular, heart sounds normal without murmurs. Bilateral lower extremities were mildly edematous. Strength in lower extremities was 4/5 proximal and distally. Labs were notable for normocytic anemia, troponin 1.05, elevated anion gap 18, lactate 1.8, creatinine 3.3 from a baseline of 1 and BNP 1425. ECG showed sinus rhythm with frequent premature atrial contractions. Chest Xray on admission was unremarkable. Additional labs were negative drug screen, normal cortisol, urinalysis. Blood cultures were sent. Overnight, the patient developed tachycardia and atrial fibrillation with rapid ventricular rate. Cardiology was consulted, bedside echo was suspicious for low left ventricular ejection fraction. The patient was anticoagulated with heparin. TSH was sent. He was requiring 2 vasopressors to maintain MAP>65. CT chest abdomen pelvis was unremarkable except stable pulmonary nodule. Patient became hypoxic on Day 2 of admission, CXR now showed features of pulmonary edema. TSH returned less than 0.01, free T4 4.69 Endocrinology was consulted, methimazole was started for thyrotoxicosis. Formal TTE showed LVEF 20-25% with global reduction in left ventricular contractility, dilated left atrium and mild MR. He was given furosemide for pulmonary edema. TSI and TRAB were positive indicating Grave’s disease. He was successfully transferred out of the ICU. Patient gradually became euvolemic with significant improvement in energy, appetite and functional capacity. He was able to participate in physical therapy and was eventually discharged to rehab. Conclusion: This case addresses an uncommon but potentially life-threatening cause of undifferentiated shock. Physical exam, history and high degree of suspicion are key in early identification and treatment. Although thyroid cardiomyopathy is rare, Grave’s disease is common and ruling our thyrotoxicosis should be included in preliminary work up of undifferentiated shock. Presentation: Friday, June 16, 2023