PULMONARY EMBOLISM IN THE SETTING OF THYROID STORM: DURATION OF ANTI-COAGULATION

Abstract

SESSION TITLE: Fellows Pulmonary Vascular Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thyroid storm is an uncommon, life-threatening presentation of hyperthyroidism with a high mortality rate. It carries an increased risk for thromboembolic diseases and pulmonary embolism (PE) which leads to increased mortality of this condition. Generally, life-long anticoagulation is used. CASE PRESENTATION: 61-year-old female, with hyperthyroidism and hypertension, presented with 3 days of shortness of breath with minimal exertion and right sided chest pain. She reported fatigue, poor sleep, palpitations, poor appetite, diarrhea, and 20 lb. weight loss. Her physician discontinued her Methimazole due to “normal thyroid tests” one month ago. She had sinus tachycardia (150s) and fever (101.8 F.) in the emergency department. CT of the chest showed bilateral pulmonary emboli (Figure 1). Her blood work demonstrated a leukocytosis with left shift, an undetectable TSH, and a low free T4. She was diagnosed with thyroid storm with a Burch-Wartofsky scale of 50 points (fever, diarrhea, and tachycardia). She began propylthiouracil, propranolol, hydrocortisone, and full dose enoxaparin. Her symptoms improved rapidly. She was switched to Apixaban and Methimazole prior to discharge. She received 3 months of anticoagulation and then chose to stop due to personal preference. The risk of recurrent PE was explained to the patient. She has been off anticoagulation for a year without recurrence. DISCUSSION: Thyroid storm is a rare (0.57-0.76 cases/100,000 US persons per year)1 condition and carries an increased risk for PE. It carries a mortality between 10-20%.2 Treatment is full dose anticoagulation and the duration is usually life-long. If we hypothesize that the hypercoagulable state resolves with the resolution of the hyperthyroid state, then anticoagulation should be safely discontinued. A retrospective case-cohort study by Lin et al. showed that the incidence of incident PE is 2.31 times more common in patients with hyperthyroidism compared to controls after adjustments for several confounders.3 CONCLUSIONS: Thyroid storm and hyperthyroidism are hypercoagulable states. Initial treatment with full dose anticoagulation is needed. However, the risk for thromboembolic events is not well studied after resolution of the hyperthyroid state. To our knowledge, only one retrospective case-cohort study showed an increased risk of thromboembolic disease in a 5-year follow-up period. Based on that study, life-long anticoagulation is warranted but future randomized trials are needed to establish this association and study the best duration of anticoagulation. Reference #1: Galindo RJ, Hurtado CR, Pasquel FJ, 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):36-43. Reference #2: Min, T., Benjamin, S., & Cozma, L. Thromboembolic complications of thyroid storm, Endocrinology, Diabetes & Metabolism Case Reports, 2014. Reference #3: LIN, H.-C., YANG, L.-Y. and KANG, J.-H. (2010), Increased risk of pulmonary embolism among patients with hyperthyroidism: a 5-year follow-up study. Journal of Thrombosis and Haemostasis, 8: 2176-2181. doi:10.1111/j.1538-7836.2010.03993.x DISCLOSURES: No relevant relationships by Cinthya Carrasco Barcenas, source=Web Response No relevant relationships by Amr Ismail, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Barbara Mantilla, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response No relevant relationships by David Sotello Aviles, source=Web Response No relevant relationships by Victor Test, source=Web Response No relevant relationships by Myrian Vinan Vega, source=Web Response