SAT-386 Challenges of Management of Thyroid Storm in the Setting of Acute Liver Failure

Abstract Disclosure: A. Suresh: None. W. Kuenstner: None. K.D. Burman: None. Introduction: The management of thyroid storm involves thioamides, beta-blockers, inorganic iodine, and corticosteroids. However, downstream complications such as heart failure and acute liver injury present management dilemmas. This case demonstrates a challenging situation in which thioamides were restricted due to acute liver failure. Case: A 73-year-old male with history of Graves hyperthyroidism presented with three weeks of diarrhea, fatigue, and shortness of breath. The most recent thyroid function tests were TSH 0.008 ng/dL and free T4 2.10 ng/dL one year earlier. One month prior to admission, he discontinued his propylthiouracil (PTU), 200 mg two times a day. He presented in atrial fibrillation with a heart rate of 193 beats per minute and otherwise normal vitals. Labs were notable for TSH 0.008 ng/dL, free T4 6.28 ng/dL, AST 117 units/L, ALT 69 units/L, total bilirubin 1.4 mg/dL and positive Influenza A virus. Soon after presentation and prior to intervention, he experienced cardiac arrest necessitating cardiopulmonary resuscitation, intubation, and vasopressors. After stabilization, the patient received PTU (400 mg loading dose followed by 200 mg every four hours), hydrocortisone (100 mg loading dose followed by 100 mg every eight hours), Lugol’s Iodine (0.5 mL every eight hours), and cholestyramine (4 gm every six hours) for thyroid storm. As transthoracic echocardiogram showed an ejection fraction of 25-30% and biventricular failure, beta blockade was held. Less than 24 hours after admission and initiation of PTU, he had worsening liver dysfunction with AST 9649 units/L, ALT 2225 units/L, and new kidney injury with a creatinine rise from 0.45 mg/dL to 1.29 mg/dL with minimal urine output. Peak INR during the admission was 6.4, peak PT was 52.3 seconds, PTT was 72.7 seconds, and factor VIII activity was elevated at 281%. Given the acute liver failure, thioamides were held, and lithium as well as plasma exchange were initiated; after 24-48 hours, he had only minimal improvement in his thyroid function tests. Once his transaminases improved to AST 231 units/L and ALT 140 units/L, PTU was restarted at 150 mg every four hours and liver function tests remained stable. During this time, the patient’s clinical status continued to decline, and his family made a decision to transition him to comfort care. Discussion: This case highlights how the catastrophic effects of thyroid storm, namely multiple organ failure, cardiovascular collapse, and arrhythmias, can present a challenge in utilizing the first line treatments, PTU and methimazole. Prior cases have recommended discontinuation of thioamides and initiation of therapeutic plasma exchange in the setting of liver failure with thyroid storm. Our case, however, is an example showing that in the event of severe thyrotoxicosis without clinical improvement despite plasma exchange, re-trialing a thioamide may be a reasonable approach. Presentation: Saturday, July 12, 2025