Extreme Care of the MOribund thyroid storm patient — ASN Events

Extreme Care of the MOribund thyroid storm patient (#334)

Christopher Jung 1 , Mark Kotowicz 1 , Adam Roberts 1
  1. Barwon Health, Geelong, VIC, Australia

A 31 year old man presented with significant deterioration over 1 week with lethargy, dyspnoea on exertion, palpitations and peripheral oedema. This was in the context of general decline and unintentional weight loss of 40-50kg over the preceding 12 months. The patient appeared cachectic with proximal muscle wasting, was jaundiced, had exophthalmos, a thyroid bruit and generalized oedema to the sacrum. He was hypoxic, tachycardic, tachypnoeic and had a temperature of 37.9ºC. Within hours of presenting to hospital he became hypotensive, requiring intubation and inotropic support in ICU. He was treated for congestive cardiac failure and atrial fibrillation with rapid ventricular rate. Thyroid function tests revealed a TSH of 0.03mU/L, free T4 43.7pmol/L (11.5-22.7pmol/L) and free T3 20.7pmol/L (3.5-6.5pmol/L) and a diagnosis of thyroid storm was made. TSH receptor antibody was positive at 40.0 IU/L. Initial treatment consisted of carbimazole 20mg QID, Lugol’s iodine 10 drops TDS and hydrocortisone 100mg QID. The patient did not respond to initial treatment and had progressive multi-organ failure, requiring hemofiltration. There were concerns about the patient not maintaining adequate cardiac output with beta blockade and hence extracorporeal membrane oxygenation (ECMO) therapy was commenced. Once ECMO therapy was commenced, the patient was treated with beta-blockers. Within a few days, the patient was weaned off ECMO therapy, inotropic support and hemofiltration. He proceeded to a thyroidectomy and tracheostomy after 10 days of medical therapy for thyroid storm. After a period of inpatient rehabilitation, the patient was subsequently discharged home. 

Treatment of thyroid storm consists of high doses of thionamides and beta-blockers. Adjunctive treatment consists of iodine solution and glucocorticoids(1-2). ECMO therapy can be used for additional cardiopulmonary support for patients with severe acute cardiac or respiratory failure. Our patient had severe congestive cardiac failure with atrial fibrillation and rapid ventricular rate that was not responding to medical therapy. ECMO therapy was successfully used for cardiopulmonary support and facilitated the use of beta-blockers for rate control of atrial fibrillation. There is now emerging evidence that ECMO therapy can be successfully used to provide temporary circulatory support for thyroid storm patients with severe hypotension(3-4).

  1. Nayak B, et al. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006. 35(4): 663
  2. Bahn RS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011; 21(6): 593
  3. Pong V, et al. Extracorporeal membrane oxygenation in hyperthyroidism-related cardiomyopathy: Two case reports. J Endocrinol Metab 2013; 3(1-2): 24-28
  4. Hsu LM, et al. Extracorporeal membrane oxygenation rescues thyrotoxicosis-related circulatory collapse. Thyroid 2010; 21(4): 439-441