Case Presentation: A female in her 50s with no significant past medical history presented to the emergency department with a 1-2 week history of lower extremity swelling, shortness of breath, and unintentional weight loss of 40 lbs over three years. Upon examination, her vital signs revealed a heart rate of 190 bpm and blood pressure of 154/93 mmHg. She exhibited moderate bilateral proptosis, lid lag, non-tender smooth thyromegaly, tachycardia, and significant lower extremity edema. An EKG showed atrial fibrillation at 183 bpm. Laboratory tests confirmed hyperthyroidism (TSH < 0.01 uIU/mL, T3 619 ng/dL, free T4 > 8 ng/dL), and echocardiogram results suggested systolic and diastolic dysfunction with an ejection fraction (EF) of 40-50%, indicative of tachycardiac-induced cardiomyopathy. She was admitted to the ICU for suspected thyroid storm, she was treated with propranolol, methimazole, high-dose hydrocortisone, and iodine, with cholestyramine added later. A thyroid ultrasound showed a diffusely hypervascular thyroid, raising suspicions of thyroiditis. Positive autoimmune workup suggested autoimmune thyroiditis. Despite aggressive management, her hyperthyroidism symptoms persisted, necessitating a total thyroidectomy.
Discussion: Post-operatively, the patient required calcium carbonate, calcitriol, and levothyroxine supplementation. She developed symptomatic hypocalcemia, presenting with tingling and spasms due to a serum calcium level of 6.5 mg/dL, which was corrected with calcium gluconate infusion and optimized oral supplementation. Additionally, she experienced rapid atrial fibrillation after surgery, treated with IV amiodarone and successful cardioversion. A follow-up echocardiogram showed improved systolic heart function, normalization of EF, and resolution of tricuspid regurgitation. Thyroid storm is a critical and life-threatening condition, accounting for approximately one in six thyroid-related hospitalizations in the U.S. with a mortality rate of about 10%. Early recognition and management are crucial to prevent multi-organ failure. The Burch-Wartofsky Point Scale (BWPS) is an effective tool for diagnosing thyroid storm, with scores over 45 indicating strong likelihood. In this case, the patient scored 65 on the BWPS due to mild CNS effects, moderate gastrointestinal dysfunction, significant tachycardia, congestive heart failure, and atrial fibrillation, necessitating urgent ICU intervention. Definitive treatments for thyroid storm include total thyroidectomy or radioactive iodine ablation, with bridging therapies such as anti-thyroid drugs and beta-adrenergic blockers utilized for stabilization.
Conclusions: This case highlights the complexities involved in managing thyroid storm, particularly when conventional treatments fail. The patient’s challenging course underscores the importance of clinical judgment and adaptability in treatment strategies. Post-operative complications, such as hypocalcemia, further illustrate the need for careful monitoring and management after definitive interventions. Ultimately, this case reinforces the critical nature of timely diagnosis and aggressive management of thyroid storm to reduce morbidity and mortality.
