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Syndrome of inappropriate antidiuretic hormone secretion — ABIM Board MCQ

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HardEndocrinology/MetabolismSyndrome of inappropriate antidiuretic hormone secretionABIM Board

A 39-year-old with untreated Graves disease presents with temperature 40.2 C, atrial fibrillation at 170/min, agitation, vomiting and heart failure after pneumonia. Thyroid storm is diagnosed. Which treatment sequence is appropriate?

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Correct answer: B — Give thionamide, then iodine, with beta-blocker and glucocorticoid

The best answer is “Give thionamide, then iodine, with beta-blocker and glucocorticoid”. Thyroid storm requires simultaneous blockade of adrenergic effects and thyroid-hormone synthesis and release, plus glucocorticoid and treatment of the precipitating infection. A thionamide must precede iodine so the iodine load does not fuel new hormone synthesis. Radioiodine is not an acute rescue treatment, levothyroxine is contrary to the physiology, and treating infection alone leaves life-threatening thyrotoxicosis uncontrolled.

Reference: 2016 American Thyroid Association Hyperthyroidism Guideline: https://pubmed.ncbi.nlm.nih.gov/27521067/