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Lack of efficacy: case report A 50-year-old man exhibited a lack of efficacy during treatment with digoxin and diltiazem for arrhythmia [routes and dosages not stated]. The man, who had a history of hyperthyroidism, presented with fever and an altered mental status. He had been receiving thiamazole [methimazole]; however, he had low compliance. On presentation, imaging showed the right lower lobe pneumonia with effusion, and he was treated with unspecified antibacterials. Subsequently, his clinical status deteriorated, and he developed shock complicated by atrial fibrillation with rapid ventricular rate. He was treated with digoxin and diltiazem, however, his arrhythmia was refractory to the therapy. Two cardioversions with 200 Joules were attempted. He was initiated on amiodarone, which stabilised his arrhythmia. He was transferred to another hospital and was intubated for respiratory distress. Following investigations, a diagnosis of thyroid storm was confirmed. He started receiving colestyramine [cholestyramine], and the dose of thiamazole was increased. Eventually, his renal function worsened and he required continuous renal replacement therapy. On admission day 2, he started receiving saturated potassium iodide solution and the dose of colestyramine was increased. His liver function tests improved by day 3 and thiamazole was switched to propylthiouracil. Despite medical therapy, his clinical status continued to worsen with evidence of multi-organ failure. On day 4, he started receiving treatment with therapeutic plasma exchange. His clinical course significantly improved with TPE and he was extubated. After 3 weeks, he was discharged on colestyramine and thiamazole. He was no longer in atrial fibrillation as he converted back to sinus rhythm. Author comment: "His clinical status deteriorated, and he developed shock complicated by atrial fibrillation with rapid ventricular rate with documented rates in the 140–190 beats per minute. His arrhythmia was refractory to digoxin, diltiazem, and two attempts at cardioversion with 200 Joules." Miller A, et al. Thyroid Storm with Multiorgan Failure Treated with Plasmapheresis. Case Reports in Endocrinology 2019: Jan 2019. Available from: 803444272 URL: http://doi.org/10.1155/2019/2475843 - USA

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Reactions 4 Jan 2020 No. 1785