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Abstract

Introduction: Thyroid storm with cardiovascular complications is a rare but life-threatening condition.

Case illustration: A 54-year-old female with uncontrolled hyperthyroid disease presented with dyspnea and typical anginal pain. The patient presented in extremis with profound hypotension (BP 58/38 mmHg), tachycardia (HR 157 bpm), tachypnea (RR 32 breaths/min), and an SpO2 of 94% on room air. Clinical examination was notable for icteric conjunctivae and bilateral pulmonary crackles on auscultation. Hepatomegaly with tenderness was found with bilateral pitting edema and cold acral in the lower extremities. The thyroid gland was neither enlarged nor tender. The admission electrocardiogram (ECG) demonstrated atrial fibrillation (AF) with rapid ventricular response (RVR). Laboratory findings revealed elevated FT4 level, undetectable TSH, and elevated CK-MB level. With a Burch-Wartofsky Point Scale (BWPS) score of 90, a diagnosis of thyroid storm was established, which was complicated by tachycardia-induced cardiomyopathy, cardiogenic shock, and type 2 myocardial infarction (MI). The patient was treated with digoxin, dobutamine, furosemide drip, and nitrate. Propylthiouracil, dexamethasone, and propranolol were loaded for antithyroid drugs. Dual antiplatelet drugs and heparin were administered to prevent hypercoagulability. The patient was transferred to the ICU for three days and discharged six days posttreatment. Within 24 hours of discharge, the patient returned with a relapse of chest pain; while the ECG was unremarkable for acute ischemia, it was diagnostic for atrial flutter with RVR. 

Discussion: Thyroid storm complicated by multiple cardiovascular manifestations could result in significant diagnostic uncertainty and therapeutic dilemmas.

Conclusion: Individualized and aggressive patient care in those with thyroid storm complicated by cardiovascular manifestations is important to prevent clinical deterioration. 

Keywords 

Thyroid storm; Cardiogenic shock; Atrial fibrillation; Myocardial infarction; Hyperthyroidism

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