A CHALLENGE IN MANAGING THYROID STORM WITH CONCURRENT PERFORATED GASTRIC ULCER PATIENT

Abstract

INTRODUCTION/BACKGROUND
Thyrotoxic crisis can be fatal if not treated promptly. Individuals with severe thyrotoxicosis who lack a functional gastrointestinal system present an uncommon but significant therapeutic challenge with a high fatality rate. We describe a case of Graves’ disease in a thyroid storm with a concurrent perforated gastric ulcer.

CASE
A 36-year-old male presented to the emergency department with acute abdominal pain and vomiting. He also had heat intolerance and significant weight loss. He was borderline hypotensive, tachycardic with a regular pulse, and had generalized abdominal guarding. Chest radiograph showed air under the diaphragm. Thyroid function test (TFT) confirmed thyrotoxicosis with Thyroid Stimulating Hormone (TSH) <0.008 m IU/L and free T4 (FT4) 64.32 pmol/L. He was scheduled for an emergency laparotomy for a perforated gastric ulcer, thus contraindicated to taking anything by mouth. We gave him 200 mg of intravenous hydrocortisone. We did not administer an antithyroid drug because our centre did not have any intravenous or per-rectal antithyroid drug preparation. Post-operatively, his condition deteriorated, and he developed rapid atrial fibrillation which required inotropic support and synchronised cardioversion. After he was permitted to sip fluids for medication, he was started on oral propylthiouracil (PTU) and Lugol's iodine in addition to regular intravenous hydrocortisone. Following this, his general condition and thyrotoxic status improved. Upon discharge, he received oral carbimazole and propranolol. In the 2-month follow-up, he was clinically euthyroid. His anti-thyroglobulin receptor antibody level was elevated, supporting the Graves’ disease diagnosis. His TFT improved, with TSH <0.008 m IU/L and FT4 17.40 pmol/L. We further titrated down his oral carbimazole until the next appointment.

CONCLUSION
Managing a thyroid storm with concurrent perforated gastric ulcer is challenging due to limited antithyroid options other than oral medication and high mortality rates. The attending physician should collaborate with the surgical team to determine the optimal timing for oral antithyroid medication to manage the thyrotoxic crisis.