Thyroid Storm

BackgroundThyroid storm (TS) is very rare, however, a life-threatening medical condition requiring emergency treatment. Since TS is rare, published case reports and seven unpublished cases of TS diagnosed at the researchers’ facilities were analyzed to make diagnostic criteria for TS in Japan. There are no reports on differences in backgrounds between Graves’ disease patients with and without TS, from a single research facility.MethodsWe retrospectively picked up patients who had been diagnosed as having Graves’ disease with and without TS, at National Center for Global Health and Medicine Kohnodai Hospital, between January 2010 and October 2018. According to the guideline for the diagnosis of Graves’ disease and TS presented by the Japan Thyroid Association, we diagnosed patients as having Graves’ disease with and without TS. We obtained clinical and laboratory data by using electronical medical records and database after showing the opt-out.ResultsWe found 69 Graves’ disease patients without TS, and five Graves’ disease patients with TS. Graves’ disease patients with TS were significantly younger than those without TS. Graves’ disease patients with TS included a significantly higher percentage of male patients than those without TS. Body temperature and pulse rate in patients with TS were significantly higher than those without TS. Serum thyroid hormone levels and the titer of third-generation thyroid stimulating hormone receptor antibody in patients with TS were significantly higher than in those without TS. Neutrophilic leukocytosis together with eosinopenia, monocytopenia and lymphocytopenia were observed in patients with TS. Serum alkaline phosphatase level was significantly higher in patients with TS than in those without TS. Serum levels of triglyceride, high-density lipoprotein-cholesterol, and low-density lipoprotein-cholesterol in patients with TS were significantly lower than those without TS.ConclusionsOur study demonstrated significant clinical, biochemical, hematological, endocrinological and immunological differences in Graves’ disease patients with TS compared to those without TS.

Disclosure: E.D. Zhang: None. I. Hussain: None. Introduction: Thyroid storm is a rare, life-threatening manifestation of thyrotoxicosis characterized by a clinical syndrome of acute multi-organ failure, which can result in significant morbidity and mortality. Impending thyroid storm is a stage of thyrotoxicosis that may progress to thyroid storm if untreated. The aim of this study was to evaluate the demographics and outcomes of patients with thyroid storm at our institution and determine the clinical features associated with severe complications and mortality. We also evaluated the differences in clinical features and outcomes in patients diagnosed with impending thyroid storm versus thyroid storm. Methods: This was a retrospective single-center cohort study evaluating patients aged 18 years or older who were clinically diagnosed with thyroid storm or impending storm at two affiliated tertiary academic centers from 2008-2021. A search of the electronic medical record system using ICD-10 codes for thyroid storm identified patient charts which were reviewed for eligibility. Results: This study included 121 admissions, with 75 (62.0%) patients with thyroid storm and 46 (38.0%) patients with impending thyroid storm. Our study cohort was notably more racially and ethnically diverse than prior U.S. studies with 5.0% non-Hispanic White, 52.9% Black, 33.9% Hispanic, and 8.3% Asian patients. The mortality rate was 4.7%, with all patient deaths occurring in the thyroid storm group. Multivariable logistic regression analysis showed atrial fibrillation (OR 4.09, 95% CI 1.21, 13.85, p=0.02) and acute respiratory failure (OR 22.18, 95% CI 2.29, 215.19, p=0.008) to be significantly associated with a composite outcome of intensive care unit (ICU) admission or death. Comparison of impending storm and thyroid storm groups showed fever (p=0.02), acute respiratory failure (p=0.03), and ICU admission (p=0.02) to be significantly different between groups. Conclusions: This study describes the largest published single-center cohort of patients treated for thyroid storm in the United States. Furthermore, our study contributes importantly to the data for racial/ethnic minorities who are under-represented in prior studies. The mortality rate in this study is lower than most recent studies. The presence of atrial fibrillation and acute respiratory failure were noted to be significantly associated with a composite outcome of ICU admission or death, and the five fatal cases had high rates of cardiac arrest and shock. These findings suggest that complications involving cardiopulmonary compromise are clinically important in predicting severe disease and poor outcomes. Acute respiratory failure was also noted to be significantly different between impending storm and thyroid storm groups indicating that while not currently included in existing diagnostic systems, it is an important complication of thyroid storm that may have prognostic value. Presentation: 6/2/2024

Thyroid storm (TS) is a rare but life-threatening manifestation of thyrotoxicosis. Predictive features and outcomes remain incompletely understood, in part because studies comparing TS with hospitalized thyrotoxic patients have rarely been performed. Our objectives were to compare the diagnosis and outcomes in TS versus hospitalized compensated thyrotoxic (CT) patients and to assess differences in diagnostic classification using the Burch-Wartofsky scores (BWSs) or Akamizu (Ak) criteria for identifying TS. This was a retrospective cohort study of hospitalized patients during a 6-year period at an academic tertiary hospital, with age ≥ 18 years, TSH <0.01 mIU/L, and clinically diagnosed TS or CT. In-patient mortality, hospital and intensive care unit length of stay, intubation, and ventilator duration were assessed. Twenty-five TS and 125 CT patients were identified and analyzed. All but 1 TS patient received thionamides, β-blockade, glucocorticoids, and iodides within 24 hours of diagnosis. CT patients received thionamides and β-blockade alone. In the acute hospital setting, rates of fever (>100.4 °F), heart rate (>100 beats/min), altered mentation, and a precipitating event were all higher for TS than for CT patients. Altered mentation was the only clinical feature significantly different between TS and the subset of CT patients defined as TS by BWS or Ak criteria (P < .001). TS patients had greater in-patient mortality, hospital and intensive care unit length of stay, and ventilation requirements than CT patients. In acutely hospitalized thyrotoxic patients, the presence of central nervous system dysfunction distinguished clinically diagnosed TS from patients with BWS- or Ak-defined TS. Because TS patients had significantly worse outcomes in this study, thyrotoxic patients with possible TS and central nervous system dysfunction may derive the greatest benefit from aggressive supportive and TS-specific treatments.

Disclosure: C. Kurimoto: None. Y. Furukawa: None. T. Akamizu: None. A. Doi: None. K. Takeshima: None. S. Morita: None. H. Iwakura: None. H. Ariyasu: None. H. Furuta: None. M. Nishi: None. T. Matsuoka: None. Context: Thyroid storm (TS), a life-threatening condition that can damage multiple organs, is caused by a combination of thyrotoxicosis and severe physical stresses. Infection is the most common triggering factor. Hypercytokinemia is a suggested background, but the pathological condition is unclear and there are no appropriate animal models. Further, TS has limited therapeutic options. Objectives: We aimed to confirm the hypercytokinemia in patients with TS, establish a TS model mouse by triiodothyronine and lipopolysaccharide administration, and explore the therapeutic effects of ghrelin on TS. Methods: We evaluated serum IL-6 levels as a representative marker of hypercytokinemia in patients with TS. As a TS model, C57BL/6 mice were titrated with triiodothyronine and lipopolysaccharide to develop a lethal model with approximately 30% survival at 24 hours. We assessed the survival ratio, mouse sepsis scores and blood biomarkers (IL-6, metanephrine, alanine aminotransferase) and evaluated the effects of ghrelin on these parameters. Results: Serum IL-6 was increased in patients with TS compared with those with Graves' disease without TS (55.7 ± 69.0 vs. 3.13 ± 1.41 pg/mL, P &amp;lt; .05, n=4 each). Next, we titrated the doses of T3 and LPS, aiming to achieve a survival rate of approximately 30% at 24 hours after administration. Two out of five mice in the T3 3.0 mg/kg group died, while none of the eight mice in the T3 1.0 mg/kg group died. Therefore, we determined that the appropriate T3 dose for the TS mouse model is 1.0 mg/kg, which is not lethal when administered alone. In the T3 1.0 mg/kg group (n=8), serum FT3 levels were approximately three times higher (15.3 ± 4.5 vs. 4.5 ± 0.7pg/ml) than those in the control group (n=8). Next, different doses of LPS was added to the T3 group. Survival at 24 hours post-dose was 60% in the T3 + LPS 0.2 mg/kg group (n=5) and 33% in the T3 + LPS 0.5 mg/kg group (n=5), while survival was 100% in the LPS 0.5 mg/kg alone group (n=5),. Based on these findings, the dosage for the murine TS model was determined to be “triiodothyronine 1.0 mg/kg and lipopolysaccharide 0.5 mg/kg”. This TS model group had increased mouse sepsis score, serum IL-6, metanephrine and alanine aminotransferase. In this model, the ghrelin at 300 µg/kg improved the survival rate to 66.7% (P &amp;lt; .01, vs. 0% [saline-treated group]) as well as the mouse sepsis score, and it decreased the serum IL-6 and metanephrine. Conclusion: We confirmed the hypercytokinemia in patients with TS. Next, we established a lethal model simulating TS by inducing “thyrotoxicosis” by exogenous administration of thyroid hormones, and by inducing “sepsis” by intraperitoneal administration of LPS. The model mice exhibited similar pathophysiological status to human TS associated with induction of serum IL-6 and other biomarkers, which were improved by ghrelin. Presentation: 6/1/2024

Background: Thyroid storm (TS) is a rare, life-threatening disease that is associated with significant mortality. The clinical outcome of these patients has not been evaluated in general practice on a national scale. Our study aimed to find the clinical characteristics and outcomes of patients admitted to community hospitals with TS using the National Inpatient Sample (NIS) database.Methods: We conducted a retrospective study of adult patients (>=18 years of age) diagnosed with primary and secondary TS from the NIS database from 2012 to 2014. The NIS is the largest all-payer inpatient care database in the United States, containing data on more than seven million hospital stays each year. Statistical analysis performed included Chi-Square test, Wilcoxon two-sample test, Fisher’s exact test and multiple logistic regression with a p-value<0.05 considered significant.Results: In total, 2,163 hospitalizations with TS were identified. The incidence of TS in hospitalized patients was 11.96 per 100,000 hospitalizations. Compared to all other adult hospitalizations reported over the same period, admission with TS was significantly associated with a higher prevalence in African Americans (31.4% vs 14.7%, p<0.001) as well as concomitant blood diseases (31.4% vs 21.9%, p<0.001), drug use disorder (11.4% vs 8.4%, p<0.001), electrolyte disturbance (36.9% vs 23.8%, p<0.001), and psychosis (38.1% vs 28.5%, p<0.001). Admission with TS was associated with lower prevalence of concomitant cancer (2.5% vs 4.9%, p<0.001) and renal disease (5.6% vs 12.2%, p<0.001), along with a higher risk of death during hospitalization (3.9% vs 2.2%, p<0.001). There was no significant association between TS and GI disease, cardiovascular disease, pulmonary disease or rheumatoid arthritis. Admission with TS was associated with longer average length of stay (TS median: 4 days, Non-TS: 3 days, p<0.001) and higher total hospital charge (TS median: $27,360, Non-TS: $24,346, p<0.001). Additionally, TS had a higher incidence in urban populations with large hospitals.Overall, inpatient mortality rate was 3.9%. For those with TS, the odds of inpatient death were greater for age group 30-59 compared to <30 (OR 2.916, p=0.026), age group >60 compared to <30 (OR 3.157, p=0.022), males (OR 2.20, p<0.001), those with cancer (OR 6.42, p<0.001), those with electrolyte disturbance (OR 6.12, p<0.001) and those with a neurologic disorder (OR 2.46, p=0.002). Admitted patients with a concomitant psychological disorder had lower odds of death (OR 0.38, p=0.03).Conclusions: This study identified clinical characteristics associated with TS-related admission including female gender, age 30-59, Caucasian race, and urban populations. Higher mortality was associated with patients 30-59 years and >60 years of age, electrolyte disturbances, blood disease, weight loss, paralysis, cancer, renal disease, and male gender.

Thyroid storm is a rare condition with a high mortality rate. Even if diagnosed early, death can occur, and reported mortality rates have ranged from 2% to 75% in hospitalized patients (1–3). Most immediate causes of death from fulminant thyrotoxicosis have been described as sudden cardiovascular collapse, with shock and arrhythmias including ventricular fibrillation. The cases have usually been described as resistant to all the usual resuscitative efforts (4). An accurate estimation of the incidence of thyroid storm is impossible to determine because of the considerable variability in the criteria for its diagnosis. Furthermore, prospective studies are impossible to conduct in a disease of such rarity on the one hand and acute occurrence on the other. With the available current therapeutic resources, death from thyrotoxicosis or from its treatment should be rare, and thyroid storm does indeed appear to be occurring less frequently today than in the past. This is most likely due to more widespread information among physicians and the general population on thyroid diseases in general and thyrotoxicosis in particular, as well as better diagnostic instruments to ensure earlier diagnosis and treatment of thyrotoxicosis. This improved management would thus preclude progression of thyrotoxicosis to the crisis stage. Nevertheless, as described very recently, it may occur in 1% to 2% of hospital admissions for thyrotoxicosis (5), and must therefore still be considered one of the more important and prevalent endocrine emergencies. In the July 2012 issue of Thyroid, a landmark study by Akamizu et al. (6) described two stepwise national surveys of thyroid storm in Japan that looked at its incidence, diagnostic criteria, clinical features, mortality, and prevalence of survival with complications. The authors first developed diagnostic criteria based on 99 patients in the literature and seven of their own patients. Thyrotoxicosis was a prerequisite for both sets of diagnostic criteria. Additional criteria were a combination of classical features such as central nervous system manifestations, fever, tachycardia, congestive heart failure and gastrointestinal (GI)/hepatic disturbances. Similar parameters were also considered by Burch and Wartofsky (1). Using these criteria, Akamizu et al. (6) subsequently conducted two nationwide surveys from 2004 to 2008, targeting all hospitals in Japan. The purpose of the first survey was to identify cases of thyroid storm. The second survey was intended to obtain detailed clinical and laboratory information regarding these cases. It is important to note that the followup survey did not stop with obtaining the information provided in the forms filled out by the respondents. As a further step, the information was vetted and respondents were contacted to fill in gaps in the data. Ultimately, Akamizu et al. (6) identified 282 patients who were assigned the diagnosis of thyroid storm, grade 1 (TS1) and 74 patients who were assigned the diagnosis of thyroid storm, grade 2 (TS2). Readers should recognize that this terminology (i.e., TS1 and TS2) was developed after the authors completed the study. In developing the initial criteria for the diagnosis of thyroid storm, one that was based on a review of the literature, the authors formulated criteria for what they referred to as ‘‘definite thyroid storm’’ and ‘‘suspected thyroid storm.’’ This terminology was used in their surveys and data records. The results of the study were, however, at odds with ‘‘definite’’ and ‘‘suspected’’ as appropriate terminologies. Thus, based on the final diagnostic criteria for each of these categories, one can calculate that the mortality rate of suspected thyroid storm, 9.9%, was almost as high as the mortality rate of definite thyroid storm, 10.9%. Given these observations, and the fact that the mortality rate of thyrotoxic patients without thyroid storm was less than 1%,* it seemed better not to use ‘‘suspected’’ for a group that had such a high mortality. Hence the terminology TS1 and TS2 were used. In addition to developing their own diagnostic criteria, Akamizu et al. (6) assigned to the patients the scores for thyroid storm proposed by Burch and Wartofsky (1) based on their seminal review of the literature. They noted that median scores (ranges) of patients with TS1 was 70 points (15–120), and those of patients with TS2 was 52.5 (25–90) points. Patients fulfilling TS1 criteria thus had a more evident disease burden and were notable for the presence of neurological

Current evidence on the incidence and outcomes of patients with thyroid storm in the United States is limited to single-center case series. This study determined the national incidence of thyrotoxicosis with and without thyroid storm and clinical outcomes among hospitalized patients during a 10-year period in the United States. Retrospective longitudinal analysis was conducted of clinical characteristics, mortality, hospital length of stay, and costs from 2004 to 2013. Adults (≥18 years of age) with a primary diagnosis of thyrotoxicosis with and without thyroid storm were included. To determine the incidence, outcomes, and cost of thyrotoxicosis with and without thyroid storm, the study used data from the National Inpatient Sample database, the largest public inpatient database, with a representative sample of all non-federal hospitals in the United States. Among 121,384 discharges with thyrotoxicosis during the study period (Mage ± standard error = 48.7 ± 0.11 years; 51.9% Caucasian; 77.3% female), 19,723 (16.2%) were diagnosed with thyroid storm. During the past decade, the incidence of thyroid storm ranged between 0.57 and 0.76 cases/100,000 U.S. persons per year, and 4.8 and 5.6/100,000 hospitalized patients per year. Thyroid storm was associated with significantly higher hospital mortality (1.2-3.6% vs. 0.1-0.4%, p < 0.01) and longer length of stay (4.8-5.6 vs. 2.7-3.4 mean days, p < 0.001) compared to patients with thyrotoxicosis without storm. Inflation-adjusted hospitalization costs progressively increased in patients with thyroid storm from $9942 to $12,660 between 2004 and 2013 (p < 0.01). One of every six discharges for thyrotoxicosis was diagnosed with thyroid storm. Thyroid storm is associated with a 12-fold higher mortality rate compared to thyrotoxicosis without storm. The incidence and mortality of thyroid storm has not substantially changed in the past decade. However, hospitalization costs have significantly increased.

Thyroid storm during induction of anesthesia

BackgroundThyroid storm is a condition in which multiple organ dysfunction results from failure of the compensatory mechanisms of the body owing to excessive thyroid hormone activity induced by some factors in patients with thyrotoxicosis. While diabetic ketoacidosis (DKA) is an important trigger for thyroid storm, simultaneous development of DKA and thyroid storm is rare.Case presentationA 59-year-old woman with no history of either diabetes mellitus or thyroid disease presented to our hospital because of developing nausea, vomiting and diarrhea for 2 days. Physical examination showed mild disturbance of consciousness, fever, and tachycardia. There were no other signs of thyrotoxicosis. Laboratory studies revealed elevation of random blood glucose and glycosylated hemoglobin, strongly positive of urine acetone, and metabolic acidosis. Since DKA was diagnosed, we initiated the patient on treatment with administration of insulin and adequate fluid replacement. Although the hyperglycemia and acidosis were immediately relieved, the disturbance of consciousness and tachycardia remained persistent. Levels of FT3 and FT4 were extremely high and TSH was below the detectable limit. TRAb was positive. The thyroid storm score of Burch & Wartofsky was 75/140, and the thyroid storm diagnostic criteria of the Japan Thyroid Association were satisfied. Oral administration of thiamazole, potassium iodide and propranolol resulted in immediate relief of the tachycardia.DiscussionWe encountered a case of thyroid storm associated with Graves' disease covered by DKA. Thyroid storm and DKA are both potentially fatal, and the prognosis varies depending on whether or not these conditions are detected and treated sufficiently early. The thyroid storm diagnostic criteria prepared in 2008 by the Japan Thyroid Association are very simple as compared to the Burch & Wartofsky scoring system for thyroid storm. The Japanese criteria may be useful in the diagnosis of this condition since they enable clinicians to identify a broad range of cases with thyroid storm. When dealing with cases of DKA or thyroid storm, it seems essential to bear in mind the possibility of the coexistence of these two diseases.

Thyroid storm is a rare and life-threatening disease. However, its prevalence, incidence, and mortality rate in Chinese population are unknown. We performed a retrospective study using the Taiwan Health and Welfare Data. Patients admitted owing to thyrotoxicosis were divided into thyroid storm group and non-thyroid storm group. We assessed thyroid storm prevalence, incidence, complications, and mortality rate. Multiple Cox regression was performed to estimate the hazard ratio for the mortality risk. Overall, 1244 thyroid storm patients and 83,874 thyrotoxicosis patients without thyroid storm were included. Most thyroid storm patients were female (67.9%) with ages ranging from 30 to 44years (33.4%), and most thyroid storm cases occurred during the summer season. The prevalence of thyroid storm was 1.48% (1244/83,874). The incidence rate of thyroid storm was 0.55 per 100,000 persons per year and 6.28 per 100,000 hospitalized patients per year. The overall 14-, 28-, and 90-day mortality rates of thyroid storm patients were 5.23%, 6.59%, and 8.12%, respectively. Thyroid storm, older age, male, and underlying ischemic stroke, myocardial infarction, heart failure, kidney disease, atrial fibrillation, depression, chronic obstructive pulmonary disease, diabetes mellitus, cancer, end stage renal diseases were associated with a significantly higher risk of mortality. In conclusion, the 90-day mortality rate of thyroid storm was high and was commonly associated with multiorgan failure and shock. Therefore, clinical physicians should identify thyroid storm and treat it accordingly.

When the storm passes unnoticed—A case series of thyroid storm

Thyroid storm is a presentation of severe thyrotoxicosis that has a mortality rate of up to 20% to 30%. Fulminant hepatic failure (FHF) entails encephalopathy with severe coagulopathy in the setting of liver disease. It carries a high mortality rate, with an approximately 60% rate of overall survival for patients who undergo orthotopic liver transplantation (OLT). Fulminant hepatic failure is a rare but serious complication of thyroid storm. There have been only 6 previously reported cases of FHF with thyroid storm. We present a patient from our institution with thyroid storm and FHF. A literature review was performed to analyze the outcomes of the 6 additional cases of concomitant thyroid storm and FHF. Our patient underwent thyroidectomy followed by OLT. Her serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, and transaminase normalized, and she was ready for discharge within 10 days of surgery. She has survived without complication. There is a 40% mortality rate for the reported patients treated medically with these conditions. Of the 7 total cases of reported FHF and thyroid storm, 2 patients died. Only 2 of the 7 patients underwent thyroidectomy and OLT--both at our institution. Both patients survived without complications. Thyroid storm and FHF each independently carry high mortality rates, and managing patients with both conditions simultaneously is an extraordinary challenge. These cases should compel clinicians to investigate liver function in hyperthyroid patients and to be wary of its rapid decline in patients who present in thyroid storm with symptoms of liver dysfunction. Patients with rapidly progressing thyroid storm and FHF should be considered for total thyroidectomy and OLT.

Thyroid storm is an uncommon but life-threatening presentation of thyrotoxicosis with a mortality rate of 10%. Our objective was to study the demographics, clinical and biochemical characteristics, and outcomes of inpatients diagnosed with thyroid storm in the Indian context. This retrospective study was conducted by analysing the institutional electronic medical records (EMR) of all patients admitted with thyroid storm from 2004 to 2020 with a Burch-Wartofsky score (BWS) of ≥45. Thirty-five patients with a BWS ≥45 were included, of whom 71.4% were women, with a mean age of 44.9 ± 10.2 years. 43% did not have any prior history of thyrotoxicosis. Graves' disease was the most common underlying aetiology (71.4%), followed by toxic multinodular goitre (14.3%). Cardiovascular (94.3%) and gastrointestinal-hepatic dysfunction (88.6%) were the most common clinical manifestations. Features of Central nervous system (CNS) dysfunction were seen in only 42.3% of patients diagnosed with a thyroid storm. The Japanese Thyroid Association (JTA) criteria diagnosed only 26 patients (74.3%) with "definite" thyroid storm. The mortality rate was 8.6%, and all three patients expired within 48 hours of admission. Nearly one in every two patients with thyroid storm had previously undiagnosed thyrotoxicosis. Toxic multinodular goitre is a notable aetiology in Indians. Features of CNS dysfunction, considered relatively specific for thyroid storm, were less prominent in our series. The JTA criteria might alter the classification of some patients diagnosed with a thyroid storm, when compared to the BWS score due to fewer CNS features among Indian patients.

Thyroid storm is a critical condition with high mortality, presenting with fever, tachycardia, and altered mental status, and is often misdiagnosed as sepsis. This report describes a case of thyroid storm initially managed as sepsis in a 68-year-old male with multiple comorbidities. After persistent tachycardia and minimal response to sepsis protocol, thyroid function tests were obtained, confirming thyroid storm. This case underscores the need to consider thyroid storm in patients with unexplained fever and tachycardia, especially when standard treatments are ineffective. We present a case of a 68-year-old male with a history of Crohn's disease, atrial fibrillation, and coronary artery disease who presented with severe weakness, fever, and confusion. Initial examination revealed a temperature of 38.5°C, heart rate of 141 bpm, and WBC count of 23,000. Labs showed mild lactic acidosis, anemia, and a slight troponin rise. Thyroid tests later indicated elevated T4 (2.250 ng/dL) and undetectable TSH (&amp;lt;0.005 μIU/mL). Despite initial treatment for sepsis and atrial fibrillation with rapid ventricular response (RVR), including IV fluids, antibiotics, and IV Diltiazem, the patient's symptoms persisted. Thyroid storm was diagnosed, and treatment with Propylthiouracil, Propranolol, and Hydrocortisone led to clinical improvement. This case highlights the diagnostic challenges of thyroid storm, a rare but serious condition that mirrors sepsis with features such as fever, tachycardia, and altered mental status. Without timely treatment, thyroid storm can lead to cardiovascular collapse and multi-organ failure, with mortality reaching up to 30%. The overlap of symptoms with sepsis and reliance on SIRS criteria often delay the diagnosis and appropriate care. In patients with unexplained fever, refractory tachycardia, or atrial fibrillation with RVR, thyroid storm should remain in the differential. This diagnostic complexity aligns with findings in other case reports, where 20-25% of thyroid storm cases are initially misdiagnosed as sepsis due to overlapping SIRS criteria. Scoring tools like the Burch-Wartofsky Point Scale can aid diagnosis, though clinicians must be vigilant for atypical presentations. Routine thyroid function testing in complex febrile presentations, particularly those with cardiac comorbidities, may support timely diagnosis and intervention. Early recognition and targeted therapy, as demonstrated in our patient, are essential to improving outcomes and reducing mortality in thyroid storm, particularly for patients unresponsive to initial sepsis treatment.

Introduction: We reported a case of patient after mitral valve replacement (MVR) with pulmonary hypertension (PH) and thyroid storm that is rare, but life-threatening condition. Case Illustration: A 57-year-old-male with a subclinical hyperthyroidism underwent MVR due to severe mitral regurgitation (MR) and high possibility for PH. He showed atrial fibrillation with normal left ventricular ejection fraction (LVEF). In the intensive care unit (ICU), four hours postoperatively, he developed thyroid storm with heart rate of 226 times/min, temperature 39oC, and thyroid function showed low TSH (&lt;0.05 uIU/mL), high fT4 (25.4 pmol/L), and high T3 (3.3 nmol/L). He was administered with propranolol, propylthiouracil, hydrocortisone, and lugol. Discussion: Trauma of cardiac surgery might trigger thyroid storm in this patient. The post-operative period represented a high-risk time for PH patients, moreover with thyroid storm. Therapy for thyroid storm was multimodal, including anti-thyroid, beta blockers, iodine, and glucocorticoid. Hemodynamic goals were avoidance of elevation in pulmonary vascular resistance (PVR), avoidance of myocardial depressants and maintenance of systemic vascular resistance (SVR), myocardial contractility and preload. Conclusion: Thyroid storm and PH complicating MVR was rare, but life-threatening. Comprehensive management could decrease morbidity and mortality of thyroid storm. Keywords: mitral valve replacement surgery; pulmonary hypertension; thyroid storm