SUN-355 Thyroid Tempest and Heartbreak: A Rare Cause of Cardiogenic Shock

Abstract Disclosure: E. Rosario Diaz: None. L. Owczarzak: None. R. Harhxi: None. T. Porter: None. Background: Thyroid storm is a rare but life-threatening condition, often triggered by infection, surgery, or untreated hyperthyroidism. This case presents an atypical presentation, mimicking rapidly progressing cardiogenic shock. Body: A 50-year-old female with a history of CAD, hyperlipidemia, SJS-TEN, end stage renal disease, and atrial fibrillation presented with weight loss, alopecia, diarrhea, and URI symptoms. On exam she was alert and oriented, warm, diaphoretic, tachypneic, and hypotensive, with tachycardia (172 bpm) and febrile (101.1°F). Lab studies showed HCO3 18 mmol/L (22 - 29 mmol/L), AG 21 (8 - 16), high sensitivity troponin 34309 ng/L (0 - 17 ng/L), lactic acid 5.9 mmol/L (0.4 - 1.3 mmol/L), WBC 16.3 K/uL (4 - 10 K/uL). Blood cultures grew pan susceptible MSSA. EKG showed T-wave inversions in I and aVL, CXR revealed bilateral pleural effusions, interstitial edema, and severe coronary artery calcifications. Transthoracic echocardiogram showed EF of 25% with global hypokinesis. The patient was started on treatment for cardiogenic and septic shock and was subsequently transferred to the cardiac ICU. Further work up revealed TSH < 0.008 uIU/mL (0.35 - 4.94 uIU/mL), free T4 > 5 ng/dL (0.7 - 1.5 ng/dL), free T3 7.42 pg/mL (1.58 - 3.91 pg/mL), TSI 0.23 IU/L (0 - 0.55 IU/L), BNP 4951 pg/mL (0 - 100 pg/mL), MvO2 55% (60-85%), CI 1.7 L/min/m2 (2.5 to 3.5 L/min/m2), CVP 18 cm H2O (5 to 12 cm H2O) indicating poor perfusion. Thyroid ultrasound showed thyromegaly without increased vascularity. Dobutamine was initiated but LHC was deferred due to her history of SJS/TEN with iodine contrast. The patient’s Burch-Wartofsky was calculated to be 85 so treatment for thyroid storm was initiated with propylthiouracil 500 mg loading dose, then 200 mg every 4 hours, and hydrocortisone 50 mg every 6 hours; potassium iodide avoided due to iodine allergy. Within 12 hours, the patient’s lab studies improved, vasopressors were discontinued and EF improved to 50-55% without motion abnormalities. She was transitioned to methimazole 40 mg daily and prednisone taper with 40 mg daily for 5 days. On outpatient follow up; methimazole was reduced to 20 mg daily. Conclusion: This case is noteworthy for its atypical presentation, with reversible cardiogenic shock in the context of thyrotoxicosis which occurs in 1-3% in patients experiencing thyroid storm. The patient’s rapid deterioration and subsequent improvement, reflected by rapidly weaned vasopressors and improved cardiac output, emphasizes the alterations in thyroid hormone metabolism driven by thyrotoxicosis. These observations shed light on the complex interplay between thyroid hormone regulation and cardiovascular function. Presentation: Sunday, July 13, 2025