SAT-601 Navigating The Storm: A Case of Thyroid Storm and Recurrent Grave's Disease after Radioactive Iodine Therapy

Abstract

Introduction: Graves’ disease is an autoimmune condition that affects the thyroid and is the most common cause of hyperthyroidism. There are three treatment options for Graves’ disease: oral antithyroid drugs, radioactive iodine (RAI) therapy and thyroidectomy. RAI therapy and thyroidectomy are considered definitive treatments. Case: A 28 year old female with a history of Grave’s Disease for 5 years ago s/p RAI-131 presented with complaints of persistent fever and chills for 1 day. The patient was diagnosed with Grave’s Disease at 22 years old and opted for RAI therapy on initial presentation of the disease as definitive therapy. The patient has been euthyroid for 5 years since RAI therapy and has never required thyroid medications. Vitals on admission were BP 132/79, T 105.6 F, & HR 113. Urinalysis on admission indicated WBCs, positive leukocyte esterase, negative nitrates, and patient was treated for possible UTI with antibiotics. On day 2 of admission, patient was found to be septic with a temperature of 101.9 F and tachycardic at 110 bpm. On day 3, patient had an episode loss of consciousness and continued to be febrile with her vitals at T 102 F, HR 100, & BP 115/80. Although the patient was euthyroid for 5 years, suspicions were raised for thyroid storm by day 3, as the patient was not clinically improving with no clear source of infection. Free thyroxin levels at this time were 2.94 (N: 0.61-1.24) and TSH 0.03 (N: 0.34-5.6). Once thyroid storm was added as a differential, the patient rapidly improved with subsequent treatment. On day 6, patient was discharged and asked to follow up with her endocrinologist. Discussion: RAI therapy and thyroidectomy are considered definitive treatments for patients with Grave’s Disease. A 2017 article by the American Thyroid Association (ATA) quoted a Mayo Clinic study outlining RAI therapy as having less than 8% failure rate compared to antithyroid medication failure rate of 48%. ATA and Mayo Clinic state that RAI therapy has the most favorable profile for the treatment of Graves’ disease. Although rare, physicians should be aware of thyroid storm and recurrent disease as a differential in any patient with a history of Grave’s Disease, despite duration of or current euthyroid status. This patient had no clinical improvement until thyroid storm was added as a differential, and with subsequent treatment, the patient rapidly improved. Conclusion: It is important to recognize that RAI therapy for Grave’s Disease may not be a definitive treatment for every patient. Physicians should consider thyroid storm in any patient with a history of Grave’s Disease, despite duration of euthyroid status.