SUN-323 - A Challenging Case of Contrast-Triggered Thyroid Storm in Chronic Amiodarone Use: Limits of Medical Therapy and the Role of Urgent Thyroidectomy

Background
Amiodarone-induced thyrotoxicosis (AIT) can be rapidly life-threatening, particularly in those with underlying cardiac disease. Guidelines recommend that patients with AIT unresponsive to aggressive medical therapy should undergo thyroidectomy.

Clinical Case
A 53-year-old man with nonischemic cardiomyopathy and ventricular tachycardia with an AICD on amiodarone therapy for the past 3 years was transferred from an outside hospital for sepsis due to a diverticular abscess. On hospital day (HD) 1, he underwent CT abdomen with intravenous iodinated contrast demonstrating a persistent sigmoid diverticular abscess. On HD 2, laboratory evaluation revealed TSH < 0.01 mIU/L, free T4 6.82 ng/dL, and free T3 9.3 pg/mL. Empiric therapy with methimazole and prednisone was initiated on HD 3 for suspected AIT. However, that evening he developed recurrent malignant ventricular arrhythmias progressing to VF/PEA arrest and subsequent profound cardiogenic shock requiring intubation and VA-ECMO support. At that point, thyroid storm in the setting of multisystem decompensation was treated with methimazole 20 mg every 4 hours, IV hydrocortisone, and cholestyramine, as well as therapeutic plasma exchange on HDs 4 and 5. Despite maximal medical therapy, thyroid hormone levels remained markedly elevated (FT4>7.0 ng/dL, FT3 >10 pg/mL), and he received additional iodinated contrast for repeat abdominal imaging on HD 4. Given refractory thyroid storm and the need for urgent source control of his intra-abdominal sepsis, on HD 7 he underwent emergent total thyroidectomy concurrently with exploratory laparotomy, partial colectomy, and end transverse colostomy. Thyroid pathology revealed diffuse follicular hyperplasia with focal granulomatous thyroiditis. Following thyroidectomy, thyroid hormone levels progressively normalized, and he was successfully decannulated from VA-ECMO on HD 15. Unfortunately, he later developed severe ARDS and multi-organ failure, expiring on HD 23.

Conclusion
Iodinated contrast exposure may exacerbate AIT type 1 and precipitate thyroid storm. Medical management in this case was complicated by severe cardiogenic shock and coexistent sepsis due to a diverticular abscess requiring urgent intra-abdominal surgery; therapeutic plasma exchange provided only transient benefit. In refractory cases, early multidisciplinary escalation to urgent thyroidectomy, even in the setting of VA-ECMO, is the only definitive intervention.

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