Beyond the Labs: Thyroid Storm Masked by NTIS Requiring ECMO

Introduction: Thyroid storm is a life-threatening form of hyperthyroidism that can lead to multiorgan failure. Severe hyperthyroidism can be precipitated by trauma, infection, surgery, acute iodine load or non adherence with antithyroid drugs. The exact mechanism of why some patients develop thyroid storm instead of uncomplicated thyrotoxicosis is not fully understood. Here we present a case of a young man with cardiogenic shock secondary to thyroid storm.


Description: A 37-year-old undomiciled man with unknown past medical history presented after a syncopal episode. He reported sore throat, dizziness, edema, weight loss, and a petechial rash for 1 month, and cough for 2 days. Vitals: BP 152/87, HR 148, Temp 103°F, SpO2 93%. He appeared cachectic with diffuse purpura. ECG showed sinus tachycardia, biatrial enlargement, and LV hypertrophy. Chest CT revealed right heart dilation with hepatic vein reflux, and multifocal pneumonia. Abdominal CT showed anasarca, mesenteric edema, and ascites. Echo revealed EF 10%, global hypokinesis, and RV dilation. Labs: TSH < 0.01, free T4 1.13, T3 76.5, TSI 72.3, TPO 239, Na 124, K 5.1, Cr 0.7. He was started on propranolol, PTU, and Lugol’s iodine for suspected thyroid storm. He developed hemodynamic collapse with PEA arrest, was intubated, and transferred to the ICU. Despite vasopressors, inotropes, corticosteroids, and methylene blue, he suffered a second arrest. He was transferred for VA-ECMO, but progressed to DIC and died despite maximal support.


Discussion: Thyroid storm is a rare, life-threatening endocrine crisis that can mimic sepsis or cardiogenic shock, often delaying diagnosis. Fewer than 1% of patients develop severe cardiomyopathy. In this case, misleadingly low T3/T4 levels likely reflected nonthyroidal illness syndrome (NTIS), masking underlying Graves disease. While BWPS helped support early treatment, it has limited value in the ICU due to physiologic overlap with sepsis. Imaging findings and thyroid antibody testing ultimately supported the diagnosis. This case highlights the importance of clinical judgment, multimodal workup, and early recognition, even when labs are inconclusive. ECMO may offer benefit in refractory cases