STORM TO SILENCE: VARIOUS ADVERSITIES AND MANAGEMENT OF HYPERTHYROIDISM (CASE SERIES FROM A TERTIARY CARE CENTRE)

Abstract Introduction: Hyperthyroidism is a grave endocrine condition that can present with complex comorbidities, life-threatening adverse effects to anti-thyroid drugs, and complications such as thyroid storm—a medical emergency necessitating rapid, individualized decisions regarding management modalities. This case series from a tertiary care centre demonstrates the implementation of alternative therapies and highlights the diverse outcomes resulting from varied treatment approaches. Case Summaries: Case 1: A 42-year-old female developed thyroid storm (Burch Wartofsky Score [BWS] 50) with mixed hepatocellular and cholestatic jaundice, suggestive of drug-induced liver injury from carbimazole. With thionamides contraindicated, management included alternative agents—Cholestyramine, Lithium, Beta Blockers, Hydrocortisone, and eventually oral steroids as there was no improvement with stopping carbimazole – leading to consideration of autoimmune hepatitis. Plasmapheresis was also indicated and led to improvement in thyroid function, and the patient stabilized post-total thyroidectomy. Case 2: A 39-year-old female on carbimazole developed severe thyroid storm (BWS 55) complicated by pancytopenia and agranulocytosis. Non-thionamide therapies (Lithium, Hydrocortisone, Propranolol, Cholestyramine), supportive antibiotics, G-CSF, plasmapheresis, and Iodine were utilized given intolerance to standard therapies. Despite aggressive intervention, she suffered a fatal cardiac arrest following multiple plasmapheresis cycles. Case 3: A 55-year-old male with hypertension and HOCM presented with impending thyroid storm (BWS 26) post-febrile illness. Managed under close monitoring with multiple therapy—Hydrocortisone, Propylthiouracil, Propranolol, and Dexamethasone. Stabilization permitted onward planning for radioactive iodine ablation, tailored to his cardiac comorbidity. Discussion: Management of thyroid storm frequently extends beyond conventional thionamides to encompass various alternative therapeutic options, dictated by drug intolerance, adverse effects, and individual patient context. These cases underscore the need for personalized, adaptable approaches and demonstrate the varied outcomes resulting from the choice and timing of interventions in hyperthyroidism.