Atypical Thyroid Storm Manifesting as Refractory Hypoglycemia and Fulminant Liver Failure in an Older Woman: A Case Report.

BACKGROUND Thyroid storm, or thyrotoxic crisis, is an acute and life-threatening manifestation or complication of hyperthyroidism that may involve sudden multisystem dysfunction. For these reasons, the initial diagnosis can be challenging. This report describes a 73-year-old woman with an atypical presentation of life-threatening thyroid storm. CASE REPORT A 73-year-old woman with no history of hyperthyroidism experienced 1 month of abdominal distension and palpitations. Upon arrival at the emergency department, she displayed profound, refractory hypoglycemia (capillary glucose 0.24 mmol/L). Within 24 hours, she developed fulminant liver failure (aspartate aminotransferase 3767 U/L, alanine aminotransferase 791 U/L), coagulopathy, and thrombocytopenia (platelets 83 000/μL). Thyroid function tests confirmed severe thyrotoxicosis (free T3 10.30 pg/mL, free T4 6.11 ng/dL, thyroid-stimulating hormone <0.008 μIU/mL), and a Burch-Wartofsky Point Scale score of 70 established the diagnosis of thyroid storm. Additional diagnoses included acute liver failure, disseminated intravascular coagulation, and heart failure (ejection fraction 43%). Conventional antithyroid drugs were contraindicated due to severe hepatic dysfunction; rescue therapies such as plasmapheresis were precluded by a prohibitive bleeding risk. After multidisciplinary counseling, the family chose palliative discharge; the patient died 3 days later. CONCLUSIONS This case demonstrates that thyroid storm can present with atypical features in patients without known hyperthyroidism, leading to delayed diagnosis and fatal multiorgan failure. Early consideration of thyroid dysfunction is essential to prevent irreversible outcomes.