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Amiodarone/hydrocortisone/propylthiouracil Rebound effect in the form of thyroid storm and infection aggravated and lack of efficacy : case report

A 51-year-old woman developed a rebound effect in the form of thyroid storm and infection aggravated following reduction of the dose of propylthiouracil and hydrocortisone. Additionally, she exhibited a lack of efficacy during treatment with amiodarone for ventricular-fibrillation [not all routes stated; time to reaction onset not stated]. The woman, who had diarrhoea and fever for 4 days, was admitted to the emergency department. She had a significant history of hyperthyroidism and atrial fibrillation for 20 years. She did not administer medication regularly and stopped taking them 6 months previously. Subsequent physical examination revealed proptosis, mild fainting, jaundice and goitre. Thereafter, thyroid function test was performed which showed an elevated serum level of free triiodothyronine (T3), free thyroxine (T4) and suppressed thyroidstimulating hormon (TSH). Based on the clinical investigation, thyroid storm was diagnosed. Therefore, she started receiving propylthiouracil 200mg, hydrocortisone 100mg every 12 hours, esmolol, propranolol and unspecified diuretics with IV therapy. Following the treatment, her temperature was normal, heart rate decreased to 100-110 beats/minute and consciousness recovered. Hence, on the next day, the dose of propylthiouracil and hydrocortisone was decreased to 100mg every 6 hours and 50mg every 8 hours, respectively. On hospital day 2, she also received hydrocortisone at the dose of 50mg every12 hours. On hospital day 4, the dose of propylthiouracil and hydrocortisone was reduced to 100mg every 8 hours and 50 mg/day, respectively. She received ertapenem from day 2 of hospitalisation. However, on hospital day 5, she developed fever with cough and weakness. Subsequent chest radiography revealed an exudative lesion of the left lung and left pleural effusion. Due to the reduction in the dose of hydrocortisone and propylthiouracil, her infection aggravated with pneumonia and large quantities of thyroxine release (thyroid storm) into the blood led to ventricular fibrillation (rebound effect). She then lost consciousness from ventricular fibrillation (circulatory collapse). Immediately, cardiopulmonary resuscitation was performed. The woman started receiving IV amiodarone 300 gram injection. Following the amiodarone therapy, her blood circulation recovered. Electrocardiogram after resuscitation showed atrial fibrillation and changed the ST-T segment. Even after amiodarone therapy, her spontaneous circulation did not maintain. Eventually, she died due to cardiac arrest. Shang W, et al. Malignant arrhythmias as the unmasked manifestation of thyroid storm. International Journal of General Medicine 13: 693-698, Jan 2020. Available from: 803518643 URL: http://doi.org/10.2147/IJGM.S265833

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Reactions 5 Dec 2020 No. 1833