SUN-498 A Case of Thyroid Storm with Systemic Thromboembolism

Background Thyroid storm is a rare but potentially life-threatening complication of hyperthyroidism. Whilst a thyroid storm is known to be a hypercoagulable state, it remains unclear if routine anticoagulation should be initiated, especially in the absence of atrial fibrillation. Case presentation A 22-year-old seaman presented to Accident and Emergency Department with a history of severe generalized abdominal pain and vomiting for 9 days. He was previously well with no significant past medical history. On examination, he appeared very anxious and agitated. He had sinus tachycardia (170 beats/min), was normotensive (Blood pressure 116/90 mmHg). He had exophthalmos, lid lag, a diffusely enlarged goiter with bruit and fine tremors on outstretched hands. There was generalized abdominal tenderness with guarding and sluggish bowel sounds. Electrocardiogram confirmed sinus tachycardia. Laboratory results showed primary hyperthyroidism [Free T4 66.2 (0.8–14.4 pmol/L), TSH <0.010 (0.65–3.70 MU/L)]. TSH Receptor Antibody was elevated at 6.23 IU/L (<1.76 IU/L), consistent with Grave’s Disease. He had acute renal impairment [urea 10.8 (2.7–6.9 mmol/l), creatinine 221 (54–101 umol/l)]. Burch & Wartofsky score was 60. Treatment with rectal propylthiouracil (PTU), i.v sodium iodide and i.v hydrocortisone were initiated. An initial CT Abdomen on Day 1 of admission demonstrated a long segment of jejunitis and marked distension of the duodenum, stomach and oesophagus. 4 days later, fT3 and fT4 levels had improved as did tachycardia and his confusion state, yet he remained febrile. Blood and urine cultures did not reveal any causative organisms. A contrast-enhanced CT revealed extensive thromboses of the portal, superior mesenteric, right external iliac, common femoral veins with left lower lobe pulmonary embolism. Thrombophilia screen was normal. He was given low-molecular-weight heparin and required total parenteral nutrition in view of prolonged bowel ileus from mesenteric ischaemia. Rectal PTU was continued to treat thyrotoxicosis. He made sufficient progress with improvement of the bowel ileus with s.c enoxaparin and was discharged 6 weeks later on oral carbimazole (on discharge: fT4 10pmol/L, TSH<0.010). However, due to extensive thromboses within the mesenteric venous system and consequent ischaemic jejunitis, he required a jejunectomy eventually 2 weeks later. Radioiodine ablation was subsequently given and he is currently hypothyroid requiring thyroxine replacement. Conclusion Extensive systemic thromboembolism may occur in the setting of a thyroid storm. Routine prophylactic anticoagulation should be considered, even in the absence of atrial fibrillation. References 1. Lin HC et al. Journal of Thrombosis and Haemostasis 2010, 8: 2176–2181 2.Kootte et al. Thromb Haemost 2012; 107: 417–422 3. Franchini et al. Clinical and Applied Thrombosis 2010, 17(4) 387–392