DOUBLE WHAMMY

CIRCULATORY COLLAPSE AND LIVER DYSFUNCTION IN THYROID STORM

Abstract

INTRODUCTION/BACKGROUND
Liver dysfunction is not an uncommon association in patients presenting with thyroid storm and could limit the treatment armamentarium. Circulatory collapse precipitated by the use of long-acting non-cardioselective beta-blockers in certain groups of patients can complicate the course of the disease.

CASE
We report three cases of thyroid storm with circulatory collapse and ischemic hepatitis complicating the use of beta-blockers and thionamides. All were females in their 40’s. Two presented with rapid atrial fibrillation (ventricular rate 158- 196 per minute) and biventricular failure, and one with acute pulmonary oedema. All developed hypotension required inotropic support; two after betablocker and one after intubation. Their free T4 was 53.6 pmol/L to 74.3 pmol/L, Burch-Wartofsky scores were 60- 95. All received ventilatory support and were treated for sepsis. They received thionamides, glucocorticoid, Lugol’s iodine, antiarrhythmic and one received cardioversion. All developed ischemic hepatitis with transaminases increased from the initial 2-7 x to 10-80 x upper limit of normal, and two had coagulopathy. Thionamide dose was reduced in two and withheld temporarily in one. Cholestyramine was added as an adjunct for all. All responded to therapy. Two were discharged with carbimazole and beta-blocker. Unfortunately, one succumbed despite initial improvement due to hospital-acquired infection.

CONCLUSION
Although beta blockers play an important role in the management of thyroid storm, caution should be exercised due to its potential life-threatening side effect especially in the presence of clinical or subclinical thyro-cardiac disease. Lugol’s iodine and cholestyramine are useful adjuncts in the presence of severe liver dysfunction when choices of antithyroid drugs are limited.