History of Presentation:
A 31-year-old man with a history of hyperthyroidism presented with five days of lower extremity swelling and shortness of breath. He had been on methimazole as an outpatient for several years, but had not taken it for several weeks due to loss of his insurance. On admission he had an irregular heart rhythm with rates up to 200bpm and a blood pressure of 110/70. An EKG was done showing rapid atrial fibrillation.
Laboratory data was consistent with thyroid storm. He was initiated on propranolol, PTU and hydrocortisone with admission to the ICU. Heart rates continued to be elevated and he was started on an esmolol drip. With rate control he became confused, lethargic, cold and hypotensive.
A bedside echocardiogram was performed showing 4 chamber dilatation and bi-ventricular failure with an ejection fraction of 5%. Laboratory data showed developing shock (table 1). He was started on norepinephrine and taken to the cath lab for invasive hemodynamic evaluation.