Thyroid Storm Research Articles (Page 1)

Severe lymphocytopenia, febrile granulocytopenia, and leukopenia induced by methimazole (MMI) are extremely rare. A 26-year-old Han Chinese female with hyperthyroidism was admitted to the hospital with fever and tonsillar enlargement after taking MMI tablets for 1 month. Adverse drug reactions correlation analysis revealed this as a novel severe adverse reaction. The patient was diagnosed with agranulocytosis with fever, thyroid storm, acute suppurative tonsillitis, and mild anemia. After admission, MMI tablets were discontinued. The patient received granulocyte colony-stimulating factor, Leucogen tablets, Diyu Shengbai tablets to elevate white blood cell count, methylprednisolone sodium succinate for inflammation, and cefuroxime sodium for infection control. The patient was discharged after 11 days of clinical treatment. Through the assessment of adverse drug reactions correlation and analysis of susceptibility factors, we recognized the importance of medication education and demonstrated that changes in clinical practice can save lives.

Objective Durvalumab plus tremelimumab has emerged as a key therapeutic option for unresectable hepatocellular carcinoma (HCC). This study aimed to meticulously monitor and identify its safety profile using real-world data from the Food and Drug Administration Adverse Event Reporting System (FAERS). Methods Data were retrieved from the FAERS database for HCC patients who received durvalumab plus tremelimumab between the fourth quarter of 2017 and the fourth quarter of 2024. Significant adverse event (AE) signals were identified using the odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and mu-item gamma Poisson shrinker (MGPS). Time-to-onset (TTO) was analyzed using Kaplan-Meier method and Weibull modeling. Independent risk factors for drug-related mortality were determined via LASSO-Cox regression, and a risk prediction model was developed to assess prognostic value. Results Disproportionality signals were identified in 51 preferred terms (PTs) across 16 system organ classes. Notable PTs with strong signals included immune-mediated hepatic disorder, immune-mediated enterocolitis, and cytokine release syndrome. Several unexpected AEs were observed, such as thyrotoxic crisis and ulcerative colitis. Anaphylactic reaction emerged as an unexpected signal and was categorized by the European Medicines Agency as both a designated and important medical event. TTO analysis revealed that most AEs (63.21%) occurred within 30 days of administration, with a median TTO of 25 days. The occurrence of AEs was significantly influenced by age and AE type. Both exploratory LASSO-Cox regression analysis and risk prediction model preliminarily showed that immune thrombocytopenia, immune-mediated dermatitis, immune-mediated enterocolitis, immune-mediated myocarditis, multiple organ dysfunction syndrome, and myocarditis were independent risk factors for drug-related mortality. Conclusion This pharmacovigilance study describes the safety profile of durvalumab plus tremelimumab in HCC. The findings may inform clinical monitoring strategies, though prospective studies are warranted for confirmation.

A 40-year-old lady presented with complaints of fever, jaundice, anorexia, weight loss, nausea, and vomiting. She had experienced palpitations, heat intolerance, and about 10kg weight loss within a year. But she ignored and did not seek any medical advice. Her presenting vitals were: heart rate: 124 beats per minute, regular; respiratory rate: 24 breaths per minute; blood pressure: 90/60 mmHg; and temperature: 1010F. The woman looked emaciated with the prominence of her zygomatic bones, had a mild diffuse goiter, and was severely icteric. However, there was no evidence of proptosis. Laboratory workup on admission showed significantly raised bilirubin and aspartate aminotransferase, along with biochemical evidence of hyperthyroidism. The diagnosis of Graves’ Disease was further approved by a high level of thyroid receptor antibody and diffuse enlargement of the thyroid on ultrasound. Hepatitis was also evident on ultrasound, with reduced parenchymal echogenicity and increased periportal echoes. According to the Burch-Wartofsky Point Scale, the score was 45 to categorize her as a case of thyroid storm. All relevant etiologies of hepatitis (Anti-HEV IgM, Anti-HAV IgM, Anti-HCV, HBsAg, including Anti-Nuclear Antibody (ANA), Anti-Smooth Muscle Ab, and Anti-Mitochondrial IgG) were excluded. Initially, the patient was resuscitated with fluids, and symptomatic treatment was provided. Later, she was managed with intravenous corticosteroid, carbimazole, and ß-blocker. She was discharged after two weeks with significant improvement in her clinical and biochemical profiles. [J Assoc Clin Endocrinol Diabetol Bangladesh, 2025;4(Suppl 1): S57]

Disclosure: Z. Zhu: None. X. Gao: None. G. Bai: None. H. Wu: None. Y. Huang: None. J. Zhang: None. Y. Gao: None. Y. Zhang: None.Background: Current guidelines primarily recommend TPE for thyroid storm, with limited recommendations for other indications of TPE in thyrotoxicosis. Due to the lack of randomized controlled trials, case reports and case series remain the main evidence guiding TPE in the treatment of thyrotoxicosis to date. Aim To summarize specific strategies and efficacy of TPE in different scenarios, providing guidance for TPE in thyrotoxicosis. Method A literature search of PubMed, Embase and Web of Science was conducted for case reports or case series published up to July 7, 2024 on TPE in thyrotoxicosis. The search identified 2152 records, of which 63 articles were accepted with a total of 103 patients. Results 103 patients from 63 studies and 2 from our center were involved, with a mean age of 45.8±16.6years, including 62 females. The main cause of thyrotoxicosis was Graves' disease (50.5%), followed by amiodarone-induced thyrotoxicosis (20.0%), iatrogenic thyrotoxicosis (7.6%), and others (12.4%). Indications for TPE were mainly thyroid storm (38%), contraindications to antithyroid drugs (ATD) (34.3%) and refractory to conventional therapies (24.8%), while rapid preoperative preparation was the least (2.9%). No significant difference was observed in the median TPE sessions for the above causes or indications (2.5 for thyroid storm and 3 for the others). Over time, the contraindications for ATD have become the leading indications for TPE (39.3%). Albumin (ALB) was the most common replacement fluid (47.6%), and compared to plasma, it was more significant in reducing FT3 (62.7% vs. 39.9%, P=0.0496) in total TPE course. For single TPE, ALB combined with plasma was more effective in reducing FT4 (29.14% vs. 13.38%, P=0.025) than using ALB alone, and plasma alone or combined with ALB were all superior to ALB alone in reducing AST (44.04%, 43.37% vs. -2.36%, P=0.003). A single TPE session can effectively reduce thyroid indices, primarily reducing TT4 (23.9%) and FT4 (19.6%), followed by TT3 (13.1%) and FT3 (15.7%); TRAb decreased by 48.7%. Additionally, liver enzymes were also reduced effectively, with reductions in AST (23.4%), ALT (28.3%), GGT (49.6%), and TBIL (23.3%). FT4 was a predictor of >3 TPE sessions (OR: 1.02, P=0.011) with a cutoff of 55.4 pmol/L (sensitivity: 65.38%, specificity: 70.45%, AUC: 0.71). 6 patients (5.71%) died, including 5 who took TPE due to thyroid storm. The incidence of adverse reactions was 12.4%, including bleeding or bleeding tendencies, allergic reactions and so on. Conclusion The primary indication for TPE has shifted to contraindications to ATD rather than thyroid storm, TPE effectively reduce thyroid indices and liver enzymes. TPE treatment of thyrotoxicosis has quite low mortality rate and incidence of adverse reactions, and deaths were mostly associated with TPE administered after thyroid storm, suggesting that earlier intervention with TPE may lead to better outcomes.Presentation: Saturday, July 12, 2025

Disclosure: C.I. Jaime: None. C.C. Chua: None. L. Teh: None.Thyroid storm is a life-threatening condition secondary to uncontrolled thyrotoxicosis. It usually manifests as multi-organ decompensation with fever, tachycardia, and hypertension as the commonly encountered presentations. Hepatic manifestation, such as new onset jaundice and abnormal liver function tests (LFT), is seen in patients with hyperthyroidism. However, severe dysfunction of the liver is not commonly seen as an initial presentation in Graves' Disease. We are presented with thyroid storm initially manifesting as severe jaundice from acute liver failure in the absence of intrinsic liver disease. An 18-year-old man presented with progressive jaundice associated with pruritus, acholic stools, and tea-colored urine and was noted to have elevated outpatient labs: alanine transaminase at 426 U/L (N:<50 U/L), aspartate aminotransferase at 282 U/L (N:<50 U/L), and normal sized liver with parenchymal disease on abdominal ultrasound. During admission, persistent jaundice, along with increasing trends of LFTs, hyperbilirubinemia, coagulopathy, and sensorium changes, were noted. Thyroid function tests (TFT) were also done which were consistent with uncontrolled hyperthyroidism secondary to Graves' disease with elevated thyroid-stimulating hormone receptor antibody (TRab) at 25.71 IU/L (N:<3.10 IU/L), FT3 at 33.76 uIU/ml (N: 3.8-6 pmol/L), FT4 at 130.28 pmol/L (N:7.9-14.4 pmol/L) and low thyroid stimulating hormone (TSH) at 0.05 uIU/ml (N:0.34-5.6 uIU/ml). With a Burch-Wartofsky score of 45, thyroid storm was considered. A multimodal approach with a combination of thionamides, corticosteroids, beta-blockers, and antipyretics was not employed due to the patient's hepatotoxic state. Lithium was started as an alternative in reducing circulating thyroid hormones; therapeutic plasma exchange was also performed. LFT and TFT were markedly decreased post-therapeutic plasma exchange. Autoimmune liver causes were also ruled out hence cleared to start with Methimazole; Lithium was discontinued. Upon clinical and biochemical recovery, a liver biopsy was done, revealing normal findings. The patient was discharged clinically stable with Methimazole and steroid adjustment. The patient underwent radioactive iodine therapy with improved LFTs and TFTs. Subsequent follow-up showed the development of post-ablative hypothyroidism; hence, Levothyroxine was initiated. To conclude, the management of thyroid storm presenting with acute liver failure in the absence of intrinsic liver disease necessitates a multimodal approach when traditional therapeutic options cannot be fully employed due to hepatotoxic dysfunction. Although there is a paucity of data regarding therapeutic plasma exchange among patients with thyroid storm, this report has demonstrated its utility and efficacy, as evidenced by the decline in TFTs and the patient's clinical improvement.Presentation: Saturday, July 12, 2025

Disclosure: D. Moreno Watashi: None. D. Stasishin: None. A. Sehgal: None. W. Azzam: None. J. Ding: None. M.B. Sharma: None.Introduction: Thyroid storm is a potentially fatal condition requiring intensive care and treatment. Single Pass Albumin Dialysis (SPAD) is a highly effective but overlooked tool in the treatment of severe symptomatic thyrotoxicosis refractory to conventional therapy. However, this technique continues to be underutilized for this indication. We present a case of a patient with new-onset refractory amiodarone-induced thyrotoxicosis (AIT) precipitating thyroid storm, who was treated with SPAD. Case description: A 74-year-old male with a past medical history of coronary artery disease, ischemic cardiomyopathy, and chronic kidney disease was brought to the emergency department for shortness of breath and bilateral lower extremity swelling. He had been on amiodarone therapy for months. Labs on presentation demonstrated an undetectable TSH level, free thyroxine level of 9.68ng/dl, and a total triiodothyronine level of 309.5ng/dl. The patient was treated with maximal medical therapy including oral methimazole (120mg/day), intravenous hydrocortisone (300mg/day), Lugol’s Iodine, and Cholestyramine. Despite aggressive therapy, he showed poor response as evidenced by a slow decrease in free thyroxine levels from 10ngl/dl to 8.5ngl/dl. He then developed a non-fatal cardiac arrest due to ventricular tachycardia. Given his refractory thyroid storm, we performed SPAD daily for 5 days. Free thyroxine levels responded by decreasing over 50% from 8.5 ng/dl to 3.36 ng/dl. The patient had an improvement in symptoms as well. However, due to the protracted course of his thyroid storm and advanced ischemic cardiac disease, he eventually developed cardiogenic shock and passed away. Discussion: Extracorporeal blood purification therapies like plasmapheresis are known treatment options for hormonal removal. SPAD, most utilized for detoxification in liver failure, was introduced as a new therapy for refractory thyroid storm by Kotball et al1. Its ability to remove protein-bound toxins can provide consistent clearing of thyroid hormone, which is known to have a high binding affinity to albumin. SPAD has the advantage of not exposing patients to the risk of transfusion reactions seen in plasmapheresis. Severe thyrotoxicosis refractory to medical therapy is an indication for advanced treatment mechanisms such as SPAD. In our opinion, SPAD is a highly effective methodology and it should be utilized more frequently and earlier to reduce morbidity and mortality in thyroid storm.Presentation: Saturday, July 12, 2025

Disclosure: R. Devbhandari: None. S. Tripathee: None. H. Akbari: None. M. Shah: None. A. Kang: None. R.M. Jhingan: None.Introduction: Amiodarone, a potent antiarrhythmic, is highly effective for rate control in atrial fibrillation (AF), particularly in hemodynamically unstable patients. Amiodarone-induced thyrotoxicosis occurs in 3-10% of cases due to iodine-induced hormone synthesis and follicular cell toxicity. We report a case of thyroid storm with AF, where thyroid function improved despite IV amiodarone use. Case report 34-year-old non-verbal male with Friedreich’s ataxia, quadriplegia, and paroxysmal AF presented with tachycardia and fever. On arrival, he was tachycardic with low normal blood pressure. The electrocardiogram showed atrial fibrillation. Initial labs were unremarkable. Computed tomography (CT) scan didn’t reveal any pulmonary embolism or cardiopulmonary abnormalities but raised suspicion for cholecystitis. He soon developed AF with rapid ventricular response with heart rates 200-250 bpm, refractory to IV metoprolol, and two rounds of synchronized cardioversion. He was started on IV esmolol and digoxin. Due to persistent tachycardia and hypotension precluding diltiazem use, an IV amiodarone drip was started as per cardiology recommendation. Phenylephrine was started for inotropy due to its negative chronotropic effect. The thyroid function panel revealed TSH <0.01 mIU/L (0.35-4.94), FT4 2.82 ng/dL (0.7-1.48), and T3 53.17 ng/dL (35-193). He had no prior history of thyroid disorders and CT imaging showed no thyroid abnormalities. He was suspected to have new onset hyperthyroidism with thyrotoxicosis. He subsequently developed septic shock secondary to acute acalculous cholecystitis confirmed on a hepatobiliary iminodiacetic acid scan. Echocardiography was unremarkable. Thyroid storm was suspected in the setting of acute cholecystitis and a Burch-Wartofsky score of 65. He was treated with IV hydrocortisone, oral methimazole, IV fluids, and antibiotics which along with percutaneous cholecystostomy led to hemodynamic improvement. Hydrocortisone was tapered with the continual improvement of FT4, and methimazole was continued for new-onset hyperthyroidism, with outpatient follow-up planned for further workup. Conclusion: This case highlights the potential use of IV amiodarone in thyroid storm for refractory arrhythmia despite maximal conventional management without worsening of thyrotoxicosis, as the patient’s thyrotoxic symptoms and thyroid function improved despite IV amiodarone. IV amiodarone inhibits peripheral T4 to T3 conversion which in combination with anti-thyroid medications, preferably started before amiodarone to suppress new hormone synthesis, may help control thyrotoxicosis symptoms in the short term. However, data remain limited due to the absence of randomized controlled trials and their known thyrotoxic properties, for which further investigation is warranted.Presentation: Sunday, July 13, 2025

Abstract Disclosure: S. Alrosan: None. M. Al-Ahmad: None. B. barthel: None. Background: Thyroid diseases (hypothyroidism and hyperthyroidism) are common endocrine conditions with systemic manifestations. Gender and racial disparities in healthcare are well known, but the impact on hospital outcomes in patients admitted with thyroid disease is unclear. This study looks at mortality, health care resources utilization, and complications in hospitalized patients with thyroid disease by gender and race using NIS (2016-2020). Methods: This is a retrospective study of adult patients admitted with a primary diagnosis of hypothyroidism or hyperthyroidism from NIS (2016-2020) using ICD-10 codes. Patients were stratified by gender and race. The outcomes were in-hospital mortality, length of stay (LOS), total cost of care (TOC). Secondary outcomes were myxedema coma, thyroid storm, venous thromboembolism (VTE), acute myocardial infarction (AMI), atrial fibrillation (AF), pericardial tamponade. Multivariable logistic and linear regression were used to calculate adjusted odds ratios (aOR) and mean differences (aMD) after adjusting for demographics and comorbidities. Results: Of 77,915 patients admitted with thyroid disease, 56,925 (73%) were female and 21,050 (27%) were male. Racial distribution was 40,935 (54%) White, 18,245 (24.1%) African American, and 10,325 (13.6%) Hispanic. Mortality was lower in females than males (1.2% vs. 2.0%; aOR 0.7, 95% CI 0.51-0.90, p=0.037). Females had lower odds of AF compared to males (aOR 0.68, 95% CI 0.62-0.75, p &amp;lt; 0.001). No differences were seen for myxedema coma (aOR 0.74, p=0.201), thyroid storm (aOR 1.34, p=0.437), VTE (aOR 0.78, p=0.273), AMI (aOR 1.05, p=0.88). LOS (aMD -0.03 days, p=0.787) and TOC (aMD -$1,527, p=0.255) were similar between genders. Compared to Whites, African Americans had similar mortality (aOR 0.97, p=0.923), lower AF (aOR 0.87, p=0.029) but higher odds of other arrhythmias (aOR 1.28, p=0.009). Hispanics had lower mortality (aOR 0.63, p=0.208) but higher AMI (aOR 1.65, p=0.039). African Americans and Hispanics had lower odds of respiratory failure (aOR 0.71, p&amp;lt;0.001 and aOR 0.75, p=0.02, respectively). Hispanics had shorter LOS than Whites (aMD -0.56 days, p&amp;lt;0.001), however, TOC was not significant. Conclusion: There is a disparity in hospital outcomes among the races and genders. Females had lower mortality and AF than males. African Americans and Hispanics had different cardiac and respiratory outcomes Further research is needed to understand race-related differences, investigate underlying mechanisms and develop targeted interventions to improve outcomes. Presentation: Monday, July 14, 2025

Abstract Disclosure: N. Bhuiya: None. R. Riachy: None. S. Shah: None. B. Kodali: None. Thyroid storm, a life-threatening manifestation of hyperthyroidism, carries a high mortality risk of 8% to 25%, emphasizing the importance of prompt diagnosis and intervention. While diagnostic tools like the Burch-Wartofsky Point Scale (BWPS) are widely used to assess disease severity, they may fail to account for atypical clinical and laboratory findings such as elevated plasma lactate and ketone levels, which can indicate a more severe disease course. We present the case of a 67-year-old male with a history of COPD, schizophrenia, and previous alcohol and cocaine abuse, but no prior thyroid disease, who presented with unintentional weight loss, palpitations, dyspnea, fatigue, poor oral intake, and occasional diarrhea. On examination, the patient was afebrile, hypertensive (151/84 mmHg), and tachycardic (150 bpm). Laboratory evaluation revealed TSH &amp;lt;0.010 uIU/ml, FT4 &amp;gt;5.6 ng/dl, FT3 &amp;gt;30 pg/ml, lactate 7.6 mmol/l, beta-hydroxybutyrate 4.13 mmol/l, troponin 876 ng/l, and a left ventricular ejection fraction (LVEF) of 15% on echocardiography. Despite a BWPS score of 35, consistent with impending thyroid storm, the biochemical profile suggested a more critical presentation. Initiation of methimazole, hydrocortisone, and propranolol resulted in marked clinical improvement. The patient subsequently underwent total thyroidectomy as definitive treatment during hospitalization. Follow-up echocardiography demonstrated normalization of LVEF to 60%, highlighting the reversibility of cardiac dysfunction with timely intervention. This case underscores the importance of incorporating atypical markers such as elevated lactate and ketones into the evaluation of hyperthyroidism severity. These findings may signify a more profound systemic impact of thyroid dysfunction, warranting heightened clinical vigilance. Early recognition and aggressive management of such cases are crucial to mitigating the risk of multi-organ failure and improving patient outcomes. Presentation: Sunday, July 13, 2025

Disclosure: E. Rosario Diaz: None. L. Owczarzak: None. R. Harhxi: None. T. Porter: None.Background: Thyroid storm is a rare but life-threatening condition, often triggered by infection, surgery, or untreated hyperthyroidism. This case presents an atypical presentation, mimicking rapidly progressing cardiogenic shock. Body: A 50-year-old female with a history of CAD, hyperlipidemia, SJS-TEN, end stage renal disease, and atrial fibrillation presented with weight loss, alopecia, diarrhea, and URI symptoms. On exam she was alert and oriented, warm, diaphoretic, tachypneic, and hypotensive, with tachycardia (172 bpm) and febrile (101.1°F). Lab studies showed HCO3 18 mmol/L (22 - 29 mmol/L), AG 21 (8 - 16), high sensitivity troponin 34309 ng/L (0 - 17 ng/L), lactic acid 5.9 mmol/L (0.4 - 1.3 mmol/L), WBC 16.3 K/uL (4 - 10 K/uL). Blood cultures grew pan susceptible MSSA. EKG showed T-wave inversions in I and aVL, CXR revealed bilateral pleural effusions, interstitial edema, and severe coronary artery calcifications. Transthoracic echocardiogram showed EF of 25% with global hypokinesis. The patient was started on treatment for cardiogenic and septic shock and was subsequently transferred to the cardiac ICU. Further work up revealed TSH < 0.008 uIU/mL (0.35 - 4.94 uIU/mL), free T4 > 5 ng/dL (0.7 - 1.5 ng/dL), free T3 7.42 pg/mL (1.58 - 3.91 pg/mL), TSI 0.23 IU/L (0 - 0.55 IU/L), BNP 4951 pg/mL (0 - 100 pg/mL), MvO2 55% (60-85%), CI 1.7 L/min/m2 (2.5 to 3.5 L/min/m2), CVP 18 cm H2O (5 to 12 cm H2O) indicating poor perfusion. Thyroid ultrasound showed thyromegaly without increased vascularity. Dobutamine was initiated but LHC was deferred due to her history of SJS/TEN with iodine contrast. The patient’s Burch-Wartofsky was calculated to be 85 so treatment for thyroid storm was initiated with propylthiouracil 500 mg loading dose, then 200 mg every 4 hours, and hydrocortisone 50 mg every 6 hours; potassium iodide avoided due to iodine allergy. Within 12 hours, the patient’s lab studies improved, vasopressors were discontinued and EF improved to 50-55% without motion abnormalities. She was transitioned to methimazole 40 mg daily and prednisone taper with 40 mg daily for 5 days. On outpatient follow up; methimazole was reduced to 20 mg daily. Conclusion: This case is noteworthy for its atypical presentation, with reversible cardiogenic shock in the context of thyrotoxicosis which occurs in 1-3% in patients experiencing thyroid storm. The patient’s rapid deterioration and subsequent improvement, reflected by rapidly weaned vasopressors and improved cardiac output, emphasizes the alterations in thyroid hormone metabolism driven by thyrotoxicosis. These observations shed light on the complex interplay between thyroid hormone regulation and cardiovascular function.Presentation: Sunday, July 13, 2025

Disclosure: A. Khan: None. A. Aziz: None. H. Ahmed Elamin: None. J. Khan: None. M. Sadiq: None. F. Ata: None. S. Khalid: None. A.J. Qassim: None. M. Asif: None. A. Ahmed Elamin: None. H. Khalid: None. Z. Yousaf: None. M. Javaid: None. A. Fatima: None. J. Ikram: None. A. Brett-Morris: None. A. Donato: None. M.G. Husnain: None.Background: Hyperthyroidism (HTH) is a reversible etiology of atrial fibrillation (AFib). There is no definite evidence whether the risk of thromboembolism (TE) in AFib due to HTH is higher or lower compared to AFib without HTH. Objective: To assess the clinical outcomes and risk of TE in patients with AFib due to HTH. Methods: A systematic literature search of PUBMED, Scopus and Embase on articles reporting AFib due to HTH yielded 4938 results. 294 studies fulfilled inclusion criteria, of which 274 were included in individual patient data analysis and 20 in meta-analysis. Meta-analysis assessed the proportion of patients developing TE in patients with AFib due to HTH. The protocol was registered on PROSPERO (CRD42022352406). Results: Individual patient data analysis (274 articles) Data was available for 418 patients. The mean age was 54.8±14.8 years. The majority were females (58.1%). 58.4% had newly diagnosed HTH at the time of presentation. Graves’ disease was the most common etiology of HTH (55.7%). 22% of patients had thyroid storm. ICU admission rate was 21.3%. 15.6% had concomitant high-output cardiac failure. The mean CHA2DS2-VASc score was 1.3±1.2. 30.4% of patients were discharged on anticoagulation (80.5% on warfarin and 19.5% on direct oral anticoagulants). TE events were reported in 19.4% of patients. Patients with TE events were older (57±14 vs 52.3±14.7 years; p <0.001), predominantly females (34.4% vs. 18.8%; p = 0.008) and had a higher CHA₂DS₂-VASc score (1.6±0.2 vs. 1.2±0.1; p = 0.03) compared to those who did not have TE. There were no differences in number of comorbidities, type of thyroid disease, thyroid antibody status, and TSH level between the two groups. A statistically significant correlation was found between CHA₂DS₂-VASc score and TE events on spearman correlation analysis (p = 0.02). No correlation was found between free T4 levels at presentation and TE events development at the follow-up (p = 0.33). Meta-analysis (20 studies) A total of 20 observational cohort studies encompassing 30,729 patients with AFib due to HTH were included in the proportional meta-analysis. The pooled prevalence of thromboembolic events in this population was 11.64% (95% CI: 7.88% - 15.96%). However, substantial heterogeneity was observed among the included studies (I² = 89.3%, τ² = 0.0151, p < 0.0001), suggesting considerable variability in event rates across studies. Conclusion: Patients with AFib due to HTH with advanced age are at higher risk of developing TE events. CHA₂DS₂-VASc score can be used for risk stratification in these patients and as it correlates with the risk of TE in these patients. The pooled prevalence of TE events is 11.64%. However, there is significant heterogeneity in the literature, highlighting the possibility of publication bias that may have overstated event risks. A formal trial or registry would better answer the question of incidence of TE in HTH.Presentation: Sunday, July 13, 2025

Disclosure: K. Sanu: None. A. Al-thunaibat: None. P. Sidhu: None. A. Abualnil: None. C. Penaherrera: None.A 23 year old female with a history of hyperthyroidism initially attributed to postpartum thyroiditis, previously on Methimazole, presented to the emergency department with symptoms of tremors, anxiety, and palpitations. Her thyroid function tests (TFT) at that time revealed suppressed Thyroid-stimulating hormone (TSH) (0.04 mIU/L), normal Free T4 (1.56 ng/dL) and elevated free T3 (4.91 pg/mL). Thyroid receptor antibodies (TRAb), thyroid-stimulating immunoglobulin (TSI), and thyroid peroxidase antibodies (TPO) which were previously checked were undetectable. Her clinical presentation was highly concerning for thyroid storm with a Burch-Wartofsky Point Scale (BWPS) of 55. She was admitted to the intensive care unit (ICU), where she was treated with propylthiouracil (PTU), propranolol, and potassium iodide. Treatment with methimazole was also reinitiated which led to symptomatic improvement. Patient was discharged with endocrinology follow up and was referred for radioactive iodine (RAI) ablation which she has completed. She subsequently developed hypothyroidism and was started on levothyroxine 88 mcg daily, with ongoing improvement in symptoms and normalization of TFTs. This case highlights several key considerations in the management of antibody-negative hyperthyroidism. The development of thyrotoxicosis after discontinuation of Methimazole supports a diagnosis of Graves' disease rather than postpartum thyroiditis. As the medication is stopped, the underlying autoimmune process begins overproducing thyroid hormones which leads to a recurrence of thyrotoxicosis. Although rare, there are documented cases of patients with clinical features of Graves' disease without detectable TRAb. These negative results may be attributed to the conventional assays used. One study, Iliciki et al. reported that a small number of patients with Graves' disease did not have detectable TRAb but developed these antibodies after treatment (1). In cases of low antibody titers, the antibody assays may lack sensitivity resulting in false-negative results. A study performed by Ng HP and Kung AW demonstrated that immunization with a specific T cell epitope of thyroid peroxidase (TPO) can induce autoimmune thyroiditis in animal models (2). This highlights the role of T cell-mediated mechanisms in the pathogenesis of hyperthyroidism, bypassing the need for detectable antibodies. Increased vigilance is also needed in considering other causes of hyperthyroidism in these cases. Employing a multifaceted diagnostic approach which integrates clinical presentation, laboratory tests, and imaging play a valuable role in diagnosing and managing these patients.Presentation: Saturday, July 12, 2025

Disclosure: S. Prasad: None. M. Singh: None. S. Balasubramanian: None. M. Souleymane: None. D. Thor: None. S. Ball: None. R. Viswanathan: None. R. Patel: None. M. Lee: None. G. Das: None. A. Jala: None. A. Faizal: None. Y. Wang: None.Introduction: Myxedema Coma (MC) is a rare endocrine emergency characterized by severe hypothyroidism and cardiovascular instability. While arrhythmias are commonly associated with MC, their prevalence, risk factors, and clinical impact remain unclear. This study examines the burden and predictors of cardiac arrhythmias in MC hospitalizations. Objective: To evaluate the prevalence and predictors of cardiac arrhythmias in MC using the National Inpatient Sample(NIS) database.Methods:A retrospective cohort study of the NIS from 2015-2022 identified MC hospitalizations using ICD-10 codes. Outcomes included bradycardia, heart block (HB), atrial fibrillation/flutter (Afib/flutter), ventricular fibrillation/tachycardia (Vfib/Vtach), cardiac arrest, transcutaneous or transvenous pacing, cardiogenic shock, and vasopressor use. Multivariate logistic regression identified predictors, adjusting for demographics and comorbidities. Results:Among 8,385 MC hospitalizations, 32.3% had at least one arrhythmia. 22.6% had bradycardia, 3.89% had HB (first-degree HB most common, 2.33%), and 7.63% had Afib/flutter. 2.33% had Vfib/Vtach, 3.8% experienced cardiac arrest, and 3.4% had cardiogenic shock. Hypotension occurred in 19.6%, with 5.3% requiring vasopressors, while 0.9% needed pacing.Older age (aOR 1.3, p=0.024) and chronic kidney disease (CKD) (aOR 1.32, p=0.044) were associated with bradyarrhythmias. Afib/flutter predictors included coronary artery disease (CAD) (aOR 1.66, p=0.017), Charlson Comorbidity Index >2 (aOR 1.85, p<0.05), and age >65 (aOR 4.41, p<0.005). Gender and race were not predictors. Arrhythmias were not independently associated with mortality. Conclusion: Cardiac arrhythmias are common in MC, affecting nearly one-third of hospitalized patients, with bradyarrhythmias and Afib/flutter being the most prevalent. Advanced age, CKD, and CAD were significant predictors, while gender and race were not. Despite their high prevalence, arrhythmias were not independent predictors of mortality, suggesting other factors may play a larger role in outcomes. These findings highlight the need for vigilant cardiovascular monitoring and further research to refine management strategies in MC.Presentation: Saturday, July 12, 2025

Abstract Background and Aims Amiodarone-induced thyroid storm (AITS) is a rare but life-threatening endocrine emergency caused by excessive thyroid hormone levels. When standard medical therapies fail to achieve stabilization, plasmapheresis can serve as a life-saving intervention to reduce circulating thyroid hormones and bridge patients to total thyroidectomy. We present a successful case report demonstrating the effectiveness of plasmapheresis in managing AITS. Case Report A 49-year-old male with a history of difficult-to-control cardiac arrhythmias was started on amiodarone in 2022. In April 2024, the patient was diagnosed with mixed type amiodarone-induced thyrotoxicosis (AIT). Amiodarone was discontinued, thiamazole and prednisolone were started. However, in July 2024, he was admitted to hospital care with acute limb ischemia and required the reinstatement of amiodarone for cardiac rhythm stabilization. Subsequently, he developed a fulminant thyroid storm with undetectable TSH, free T4 levels exceeding 5.0 ng/dL, and a peak T3 of 3.91 ng/mL. Despite aggressive medical therapy with beta-blockers, corticosteroids, and antithyroid drugs, the patient's condition remained refractory, with persistent hemodynamic instability and severe thyrotoxicosis. Urgent plasmapheresis was initiated as a salvage therapy in the intensive care unit (ICU). The patient underwent three consecutive sessions of plasmapheresis, each involving the exchange of 1.5 plasma volumes. Albumin was used as the primary replacement fluid, with the addition of two units of fresh frozen plasma (FFP) at the end of each session. This approach resulted in progressive stabilization of cardiovascular parameters, as illustrated by the evolution of T3 and free T4 levels (Fig. 1). Following stabilization, the patient underwent a total thyroidectomy, resolving the hyperthyroid state. Postoperatively, the patient recovered without complications and was transitioned to lifelong levothyroxine therapy. Conclusion This case highlights the efficacy of plasmapheresis in managing refractory AIT, particularly in patients with critically thyrotoxicosis and severe clinical instability. Plasmapheresis offers rapid hormonal control by removing protein-bound thyroid hormones, bridging the gap between medical therapy and surgical intervention. Early recognition and initiation of plasmapheresis in high-risk patients, especially when standard therapies fail to control symptoms, could improve outcomes and reduce morbidity associated with AITS. Additionally, this case underscores that plasmapheresis is a safe and effective procedure, even in the intensive care unit setting, enabling timely stabilization and facilitating definitive treatment.

BackgroundGuidelines generally recommend achieving a biochemically euthyroid state before thyroidectomy in patients with an indication for surgery to reduce the risk of thyroid storm. However, in real-world settings, this may not always be feasible. This study aimed to compare perioperative outcomes between biochemically controlled (normal fT3 and fT4) and uncontrolled (elevated fT3 and/or fT4) hyperthyroid patients undergoing thyroidectomy.MethodsWe retrospectively analyzed patients who underwent thyroidectomy for hyperthyroidism at our institution between September 2020 and 2024. The demographic, perioperative, and postoperative data were collected. Patients with preoperative fT3 and/or fT4 levels above the institutional reference range were classified as uncontrolled, whereas those with both fT3 and fT4 levels within the reference range were considered controlled. The outcomes were compared between the controlled and uncontrolled groups.ResultsA total of 110 patients were included: 92 (83.6%) in the controlled group and 18 (16.4%) in the uncontrolled group. Patients in the uncontrolled group were significantly younger (median age 33.5 vs. 49 years, p = 0.015). Graves’ disease was more prevalent among uncontrolled patients (83.3% vs. 45.7%, p = 0.013). The use of Lugol’s iodine (27.8% vs. 1.1%, p < 0.001) and steroids (38.9% vs. 6.5%, p < 0.001) was significantly higher in the uncontrolled group than in the control group. Operative times and complication rates—including transient/permanent hypocalcemia, recurrent laryngeal nerve palsy, and neck hematoma—did not significantly differ between the groups.ConclusionsDespite the presence of biochemical hyperthyroidism, no thyroid storm occurred in our cohort, and complication rates were comparable between groups. These findings suggest that thyroidectomy may be performed in selected patients without full biochemical control, particularly in urgent situations or in high-volume centers with experienced surgical teams. However, biochemical euthyroidism remains the standard of care, and our results should be interpreted cautiously given the small sample size and single-center setting.

Thyroid storm, also known as thyroid crisis, is a serious medical condition that occurs when there is an extreme overproduction of thyroid hormones. It usually develops in individuals with uncontrolled hyperthyroidism, often due to diseases such as Graves' disease or thyroid adenomas. We herein report a case of a female patient with Graves' disease who presented with thyroid storm and did not respond to conventional treatment, requiring intensive care unit management and mechanical ventilation support. In addition, she was managed with plasma exchange (plasmapheresis), which stabilized her clinical and biochemical parameters. In conclusion, thyroid storm is a critical condition with multiple clinical implications that should be managed using a multidisciplinary approach; moreover, early identification and adequate treatment are essential to reduce its associated morbidity and mortality. Our case indicated that plasmapheresis should be considered for patients refractory to conventional treatment. Once the critical stage of the disease concludes, definitive treatment with total thyroidectomy should be planned. Early recognition and prompt management of thyroid storm can significantly improve patient outcomes. Multidisciplinary care is essential for addressing the systemic effects of thyroid storm. Tailored rehabilitation programs may enhance recovery from associated complications, such as paralysis.

Thyroid Emergencies: A Narrative Review.

A Curious Case of Contrast-Induced Thyroid Storm

A case of thyroid storm in a patient with persistent recurrent laryngeal nerve paralysis with review of literature

Background Thyroid storm (TS) is an acute and critical presentation of hyperthyroidism. It can lead to multiple organ dysfunction and has high rate of mortality. Heart failure is one of grave complication of hyperthyroidism and thyroid storm. Rapid progression of TS can lead to hypoperfusion and shock even with normotensive blood pressure and normal hemodynamic parameter. Unfortunately, prevalence of hyperthyroidism majority in developing area who lack of advanced medical facility.1 This case presentation aims to present the rare condition of acute high output failure secondary due to thyroid storm with hypoperfusion and normotensive shock. Case Illustration A 28-year-old man came to the emergency department of private hospital in East Borneo with worsening dyspnea on effort since three days before admission. His blood pressure was 169/103 mmHg with irregular heart rate at 135-148 bpm. His axillary temperature was 37.9° C. ECG showed rapid atrial fibrillation with Ashman phenomenon. Chest x-ray revealed cardiomegaly with flattened cardiac waist and lung infiltrate. His echocardiogram has hyperdynamic LV with LVEF 70%, normal RV function, concentric LV hypertrophy, and increased LAVi (51.19 mL/m2). From initial echocardiogram hemodynamic assessment, eRAP was 15 mmHg, CO was 6.5 to 7.4 L/min, SVR was 1167 to 1329 dyne/sec/cm-5. His peak E wave velocity was 92-95 cm/s, His fT4 was increased (100 ng/dL) while TSH was reduced (0.007 mU/L). H2FPEF score estimated 38.7% probability of heart failure with preserved ejection fraction (HFpEF). Burch-Wartofsky score was 60, suggesting thyroid storm. He was diagnosed with acute high output heart failure secondary to thyroid storm due to uncontrolled Grave’s Disease, and AF rapid ventricular respond. During follow up in intensive care unit (ICU), patients underwent hypoperfusion with normotensive blood pressure (normotensive shock). norepinephrine was initiated. Patient keep deteriorating, and then passed away in our critical care unit at day of 7th Conclusion Thyroid storm induced acute heart failure might have conundrum presentation due normotensive and good cardiac output, give false impression of hemodynamic condition. Clinical presentation was very important to identify hypoperfusion and aggressive treatment was needed to stabilize patient condition.