(294) Thyroid Storm Precipitates Biventricular Thrombi and Acute Limb Ischemia

Introduction: Thyroid storm is a dangerous and potentially deadly dysregulation of multiple organ systems, with documented but often unrecognized cardioembolic complications. Thyroid storm is known to be precipitated by supplements and herbal remedies, though exact risks are unknown.

Description: A patient in their 40s with known hyperthyroidism under the care of a naturopath presented with tachycardia, hypertension, and a cool, pulseless leg. She was found to have an occlusive arterial thrombus of the femoral artery, for which a heparin drip was initiated. The patient was then taken emergently to the operating room for endovascular thrombectomy. In the operating room, a transesophageal echocardiogram was performed to evaluate hemodynamic instability, which revealed stress cardiomyopathy and biventricular thrombi. Multimodal treatment of thyroid storm was begun intraoperatively. After successful thrombectomy, the patient lost pulses in the right lower extremity again and was found to have a newly organized occlusive thrombus. The decision was made to proceed with open thrombectomy, which was successful. Postoperatively, the patient was taken to the surgical ICU, where they were found to have hemiparesis and a new infarct of the M4 segment of the right MCA. Shortly thereafter, the patient developed atrial fibrillation with a rapid ventricular response, which was terminated with amiodarone. While in the SICU, temporary tarsorrhaphies were placed by ophthalmology for corneal epithelial defects from advanced exophthalmos. The patient's condition improved with treatment of their thyrotoxicosis and continued anticoagulation for their ventricular thrombi and cerebral infarct. They were able to be weaned from the ventilator, transferred to the floor, and eventually discharged to a rehabilitation facility.

Discussion: Thyrotoxicosis can precipitate arterial thrombi through alteration of cardiac output, stress cardiomyopathy with formation of ventricular thrombi, and inducing a hypercoagulable state. Our patient was reported to have taken commercially available thyroid supplements, which may have induced her thyroid storm and acute presentation. This case underscores the importance of careful review of supplement intake, as they continue to gain popularity and use despite a lack of federal regulation.