(293) The Perfect Storm: Pregnancy With Thyrotoxicosis, Multifactorial Shock, and Pulmonary Embolism

Tuesday, February 25, 2025

12:30pm – 1:30pm Eastern Time

Location: Connections Central - RST 14

First Author(s)

HC

Hac-Tu J. Chung, DO (she/her/hers)

Florida Atlantic University
Boca Raton, Florida, USA

Co-Author(s)

BA

Breno Andrade, MD

Resident Physician
Florida Atlantic University, United States
AS

Abid Sobhan, DO

Resident Physician
Florida Atlantic University, United States
ZS

Zachary Steinberg, DO

Resident Physician
Florida Atlantic University, United States
YF

Yehuda Fuzailov, MD

Pulmonary and Critical Care Physician
Florida Atlantic University, Baptist Health South Florida, United States

Introduction: Thyroid storm is an acute, life-threatening complication of hyperthyroidism. We present a case of a pregnant patient with untreated hyperthyroidism who developed thyroid storm, complicated by respiratory failure, cardiogenic and septic shock, and pulmonary embolism. The administration of a beta-blocker in this setting was nearly fatal.

Description: A 28-year-old female with a history of hyperthyroidism and thyroid storm presented for two weeks of cough with worsening shortness of breath. At six weeks pregnant, her initial vital signs revealed a heart rate of 140 bpm with a mean arterial pressure (MAP) of 70 and saturating 94% on room air. A chest x-ray showed a right lower lobe infiltrate, and her oxygen requirements increased to 2 liters via nasal cannula. She was started on ceftriaxone and azithromycin for pneumonia, and propranolol, propylthiouracil, and potassium iodide drops for a suspected thyroid storm. An esmolol drip was initiated which subsequently dropped her heart rate to 70 bpm with MAPs in the 40s so esmolol was immediately discontinued. A bedside point-of-care ultrasound revealed severe left-sided cardiomyopathy and mitral regurgitation, with no evidence of right heart strain. Later, the patient became persistently tachycardic in the 170s, prompting another attempt with propranolol. Unfortunately, she suffered a cardiac arrest, but spontaneous circulation returned after two minutes. She was intubated, and five vasopressors were initiated to sustain MAPs in the 50s. She had severe lactic acidosis with a level of 19.6 mmol/L. A bicarbonate drip, broad-spectrum antibiotics, and continuous renal replacement therapy were initiated. The patient tested positive for human metapneumovirus and Mycoplasma pneumoniae, and developed Streptococcus pneumoniae bacteremia. A computed tomographic angiogram of the chest revealed a right upper lobe pulmonary embolus. Sadly, the patient miscarried, but extubation was successful, and she was discharged home after a week.

Discussion: Although beta-blockade is the mainstay of treatment for thyroid storm, it is crucial to consider a broad differential diagnosis. Our patient had multiple potential causes for persistent tachycardia, including shock, cardiomyopathy, pulmonary embolism, and thyroid storm. In this case, beta-blockade was nearly fatal.