Abstract
Disclosure: C.I. Jaime: None. C.C. Chua: None. L. Teh: None.
Thyroid storm is a life-threatening condition secondary to uncontrolled thyrotoxicosis. It usually manifests as multi-organ decompensation with fever, tachycardia, and hypertension as the commonly encountered presentations. Hepatic manifestation, such as new onset jaundice and abnormal liver function tests (LFT), is seen in patients with hyperthyroidism. However, severe dysfunction of the liver is not commonly seen as an initial presentation in Graves' Disease. We are presented with thyroid storm initially manifesting as severe jaundice from acute liver failure in the absence of intrinsic liver disease. An 18-year-old man presented with progressive jaundice associated with pruritus, acholic stools, and tea-colored urine and was noted to have elevated outpatient labs: alanine transaminase at 426 U/L (N:<50 U/L), aspartate aminotransferase at 282 U/L (N:<50 U/L), and normal sized liver with parenchymal disease on abdominal ultrasound. During admission, persistent jaundice, along with increasing trends of LFTs, hyperbilirubinemia, coagulopathy, and sensorium changes, were noted. Thyroid function tests (TFT) were also done which were consistent with uncontrolled hyperthyroidism secondary to Graves' disease with elevated thyroid-stimulating hormone receptor antibody (TRab) at 25.71 IU/L (N:<3.10 IU/L), FT3 at 33.76 uIU/ml (N: 3.8-6 pmol/L), FT4 at 130.28 pmol/L (N:7.9-14.4 pmol/L) and low thyroid stimulating hormone (TSH) at 0.05 uIU/ml (N:0.34-5.6 uIU/ml). With a Burch-Wartofsky score of 45, thyroid storm was considered. A multimodal approach with a combination of thionamides, corticosteroids, beta-blockers, and antipyretics was not employed due to the patient's hepatotoxic state. Lithium was started as an alternative in reducing circulating thyroid hormones; therapeutic plasma exchange was also performed. LFT and TFT were markedly decreased post-therapeutic plasma exchange. Autoimmune liver causes were also ruled out hence cleared to start with Methimazole; Lithium was discontinued. Upon clinical and biochemical recovery, a liver biopsy was done, revealing normal findings. The patient was discharged clinically stable with Methimazole and steroid adjustment. The patient underwent radioactive iodine therapy with improved LFTs and TFTs. Subsequent follow-up showed the development of post-ablative hypothyroidism; hence, Levothyroxine was initiated. To conclude, the management of thyroid storm presenting with acute liver failure in the absence of intrinsic liver disease necessitates a multimodal approach when traditional therapeutic options cannot be fully employed due to hepatotoxic dysfunction. Although there is a paucity of data regarding therapeutic plasma exchange among patients with thyroid storm, this report has demonstrated its utility and efficacy, as evidenced by the decline in TFTs and the patient's clinical improvement.
Presentation: Saturday, July 12, 2025