SAT-311 - Thyroid Storm in A Previously Healthy Patient: An Unusual Presentation of Severe Thyroiditis

Thyroid storm is a rare endocrine emergency usually linked to uncontrolled Graves’ disease, making its occurrence in individuals without prior thyroid dysfunction exceptionally uncommon. In such patients, especially when an unusual infectious trigger is present, both severe thyroiditis and hashitoxicosis emerge as rare but important alternative etiologies capable of precipitating abrupt hormone release. Although thyroiditis is typically self-limited and far milder, destructive inflammatory processes or autoimmune activation may occasionally lead to systemic decompensation. Distinguishing between these entities can be challenging, as their clinical, biochemical, and immunologic profiles may overlap substantially. We report the case of a 61-year-old previously healthy man who presented to the emergency department with profound asthenia, fever, night sweats, cervical pain, dyspnea, and anorexia, alongside a perianal abscess, an exceptionally uncommon infectious trigger for thyroid storm. He exhibited atrial fibrillation, lethargy, and low-grade fever, achieving a Burch-Wartofsky score of 45, consistent with thyroid storm. Laboratory findings showed suppressed TSH and free T4 > 5 ng/dL. Intensive management was promptly initiated with high-dose propylthiouracil, Lugol’s solution, propranolol, hydrocortisone, antibiotics, and electrical cardioversion, resulting in sustained reversion to sinus rhythm and progressive decline in thyroid hormone levels. Furthermore, the negative TRAb and the rapid hormonal decline observed during hospitalization excluded Graves’ disease, reinforcing thyroiditis as the underlying etiology. Thyroid ultrasonography showed preserved morphology, and anti-thyroglobulin antibodies were positive. Notably, during follow-up, the patient evolved to permanent hypothyroidism, prompting discontinuation of propylthiouracil and requiring levothyroxine replacement, with later positivity for anti-thyroid peroxidase antibodies. Although thyroid storm is rarely associated with hashitoxicosis, this evolution, together with the autoimmune profile, raises the possibility of this uncommon mechanism. Taken together, these findings still favor thyroiditis as the most plausible etiology, with the perianal abscess acting as a rare infectious precipitant, while acknowledging that overlap with hashitoxicosis cannot be fully excluded. This case underscores the importance of prompt recognition and intensive management of atypical thyroid storm presentations, while illustrating how the etiologic distinction between severe thyroiditis and hashitoxicosis may remain uncertain. Such cases expand clinical awareness and reinforce the need for high suspicion in uncommon scenarios.

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