skip to main content

Thyroid storm — ABIM Board MCQ

Instant feedback + full explanation. One question, done properly.

HardEndocrinology/MetabolismThyroid stormABIM Board

A 44-year-old woman with untreated Graves disease is admitted to the intensive care unit with a temperature of 104.4°F (40.2°C), delirium, vomiting, atrial fibrillation with a ventricular rate of 154/min, and pulmonary edema. TSH is undetectable, and free T4 is markedly elevated. Supportive care and cautiously titrated esmolol have been initiated. Pregnancy testing is negative, and aminotransferase levels are normal. Which of the following is the most appropriate next pharmacologic management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Give propylthiouracil and hydrocortisone now, followed by potassium iodide at least 1 hour later

This patient has thyroid storm, indicated by severe thyrotoxicosis with hyperthermia, delirium, atrial fibrillation, gastrointestinal symptoms, and heart failure. After supportive care and cautious adrenergic blockade, give a thionamide promptly; PTU is traditionally favored initially because it inhibits both thyroid hormone synthesis and peripheral T4-to-T3 conversion. Hydrocortisone also decreases T4-to-T3 conversion and treats possible relative adrenal insufficiency. Potassium iodide should be administered at least 1 hour after PTU to inhibit release of preformed hormone. Giving iodine before or simultaneously with a thionamide may provide substrate for additional hormone synthesis. Iodine should not be withheld until euthyroidism, and radioactive iodine has no role during acute instability.

Reference: Pokhrel B, Aiman W, Bhusal K. Thyroid Storm—Treatment/Management. StatPearls. Updated October 6, 2022. https://www.ncbi.nlm.nih.gov/books/NBK448095/