Thyroid storm in an uncontrolled graves’ disease with multiple complications: a case report

Abstract

Thyroid storm is an acute and life-threatening condition. Graves’ disease is the most common cause of thyroid storm. In this case, reported an uncontrolled Graves’ disease patient with multiple complications progressing to thyroid storm. A 33-years-old woman was admitted to the emergency department with agitation. Patient had a history of uncontrolled hyperthyroidism four years ago. From physical examination found exophthalmos, bibasilar rales in both lungs, shifting dullness on stomach, swollen feet, and cold extremities. The ECG showed an atrial fibrillation with rapid ventricular response. Thyroid stimulating hormone (TSH) was found very low with 0.02 mIU/L and very high free thyroxine (FT4) with 5.04 ng/dL. The neck USG showed thyroiditis and bilateral neck lymphadenopathy. The patient was hospitalized for 9 days (4 days in ICCU and 5 days in the general ward). A very high thyroid hormone receptor antibody (TRab) of 35.9 signified a diagnosis of Graves’ disease. The patient had a total Burch-Wartofsky point scale (BWPS) score of 80 and highly suggestive of a thyroid storm. Multiple complications of Graves’ disease are cardiac failure, atrial fibrillation, seizures, vomiting, abdominal cramps, diarrhea, elevated liver enzymes, coma, jaundice, and thromboembolism while in this case the patient had cardiac failure, atrial fibrillation, and elevated liver enzymes. Thyroid storm is diagnosed with clinical features not on laboratory results. It is important to evaluate multiple complications of Graves’ disease as an early warning to reduce the mortality of thyroid storm.