Category: Thyroid

Monitor: 17

17 - PERSONALIZED MANAGEMENT OF THYROID STORM PRECIPITATED BY COCAINE ABUSE

Friday, Apr 26
12:30 PM – 1:00 PM

Objective :  To describe a rare presentation of thyroid storm precipitated by cocaine abuse. 


Methods : We present a case report with detailed medical history, diagnostic and treatment course tailored to the patient


Results : A 27-year-old man visiting from Ireland with a past medical history of poorly controlled Graves' disease for past 5 years presented to ED with altered mental status, fever and new onset atrial fibrillation with tachycardia to 180 beats per minute. Physical exam was significant for obtundation, bilateral exophthalmos and lid lag. Burch-Wartofsky Score was 90, highly suggestive of thyroid storm. Labs revealed undetectable level of Thyroid Stimulating Hormone (TSH) and markedly elevated thyroid hormones including total and free T3 and T4. Additionally, antibody panels including Thyroid Stimulating Immunoglobulin, Thyroperoxidase and TSH Receptor antibodies were all overtly positive. Notably urine toxicology was positive for cocaine. Patient was intubated for airway protection and transferred to the ICU. He was started on propylthiouracil, later switched to methimazole, stress doses of hydrocortisone and potassium iodine solution. Calcium channel blocker was used for rate control in setting of cocaine intoxication, and was later transitioned to propanolol. Methimazole was titrated down as his thyroid function tests and symptoms improved throughout his hospital course. 


Discussion :

Thyroid storm is a rare but severe, life-threatening condition with a mortality rate up to 50%. Cocaine is a commonly abused stimulant that releases catecholamine potentially precipitating symptoms for the thyroid storm. Management of thyroid storm depends on quick recognition of symptoms, evaluation of thyroid biomarkers, immediate airway protection and ICU level of care. Use of thionamides, beta-blocker or calcium channel blocker, iodine solution and glucocorticoids can be critical life-saving measures in treating the thyroid storm. Use of beta blockers should be weighed against the risks of possibly inducing vasoconstriction and increased blood pressure in patients with concurrent cocaine abuse. Extensive counselling regarding compliance to medication and dangers of illicit drug use should be emphasized in further long-term management followed by radioiodine therapy, to prevent recurrence.


 


Conclusion :

While thyroid storm is a rare disease with very high mortality rate even with or without the treatment, scarce reports have shown thyroid storm triggered by cocaine abuse. Prompt recognition and prioritizing personalized management is necessary for treating this disease.

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Elizabeth Omoniyi

Resident
Icahn School of Medicine at Mount Sinai, Mt Sinai St. Luke Hospital
New York, New York

Internal Medicine Resident PGY2

Tai Ho Shin

Fellow
Icahn School of Medicine at Mount Sinai, St. Luke, West and Beth Israel Hospital
New York, New York

Fellow in Endocrinology

Elizabeth Omoniyi

Resident
Icahn School of Medicine at Mount Sinai, Mt Sinai St. Luke Hospital
New York, New York

Internal Medicine Resident PGY2