A Case of Thyroid Storm With Takotsubo Cardiomyopathy and Multi-Organ Failure: What Is the Primary Cause of Hemodynamic Instability and How Do We Treat it?

Abstract

Introduction: Thyroid storm is a rare but life-threatening emergency. Multi-organ failure has been recognized as the most common cause of death, but conventional therapies can be limited depending on the clinical presentation. We present a case of a patient in thyroid storm who rapidly developed multi-organ failure, preventing her from obtaining potentially life-saving treatment. Case Presentation: A 68-year-old female with a past medical history of hypertension, hyperlipidemia, and Grave’s disease, who was non-compliant with medications, presented to a facility for shortness of breath after the unexpected death of her husband. She was diagnosed with a non-ST elevation myocardial infarction and new onset heart failure. At that time, her TSH level was <0.010 uIU/mL and Free T4 was 1.80 ng/dL. Imaging revealed a significantly enlarged thyroid gland measuring 8cm by 6.6cm. She was started on methimazole and discharged home. A few days after discharge, she underwent a cardiac catheterization and was found to have Takotsubo cardiomyopathy. On presentation to our facility 2 weeks later, the patient was experiencing worsening shortness of breath and anxiety. She was found to have new-onset uncontrolled atrial fibrillation with rapid ventricular response and a blood pressure of 77/38 mmHg. The Burch-Wartofsky Point Scale was calculated to be 55 points, highly suggestive of thyroid storm. TSH was < 0.010 uIU/mL, total T4 was 16.63 ug/dL, and free T4 was 3.28 ng/dL. She was initiated on propylthiouracil, cholestyramine, hydrocortisone, and esmolol. Within 12 hours, she developed fulminant multi-organ failure requiring ventilatory support and vasopressors. She also developed ischemic hepatitis and propylthiouracil was discontinued. Urgent therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) were later attempted but both therapies were not initiated due to severe hemodynamic instability. A bedside echocardiogram revealed an estimated ejection fraction of 20-25%. Due to worsening cardiogenic shock, she was evaluated for extracorporeal membrane oxygenation (ECMO) but was not a candidate. She instead underwent an emergent Impella device implantation. Despite this intervention, the patient’s clinical condition did not improve after multiple vasopressors, and the patient’s family opted for comfort-focused measures. The patient died after 1 day of hospitalization. Conclusion: A multimodality approach to treatment is recommended for patients with thyroid storm but underlying conditions such as Takotsubo cardiomyopathy and fulminant multi-organ failure may complicate the treatment plan. The complexity of this case highlights the need to understand relative contraindications to salvage therapies, such as TPE, and the role for other treatment options when patients present with co-existing multi-organ failure.