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Presentation: A 25-year-old man presented to the ED with intentional multi-drug overdose onset 9PM on the night prior to admission. PMHx is significant for seizures, hypothyroidism, resting tremors, and smoking. The patient expressed frustration over his persistent hand tremors with depressed mood and took 25 tablets of 500mg Keppra, 30-40 tablets of 150 mcg Levothyroxine, and 25 tablets of 10mg propranolol. The patient denied any chest pain, SOB, nausea, vomiting, lightheadedness, fever, focal weakness, numbness or tingling, prior SI, rash, dysuria, or bleeding. Hospital Course: Vitals were T: 37 Celsius, HR: 92 BPM, 135/87 BP, RR: 18, and SpO2: 93%. Initial EKG showed sinus rhythm with 80 heart rate. The physical exam was significant for profuse diaphoresis and generalized tremors. There were no ST or T wave abnormalities indicating ischemia. The patient had a lab workup that was significant for a TSH of 0. 006, FT4 of >5, FT3 of 7. 09, and T4 of 22.77, after which he was placed on plasmapheresis. The FT4 trended downward to 2.56 after plasmapheresis. The patient experienced transient elevations in creatine kinase and bilirubin, but lab workup was otherwise unremarkable. The patient met admission criteria for inpatient psychiatry and discharged to a psych facility. Discussion Given the 7-day half-life of Levothyroxine, plasmapheresis was considered the best option to prevent fatal thyroid storm. This case also demonstrates the importance of how a multi-drug overdose can present more benign presentation with stable vitals. In this case, the effects of propranolol masked the initial symptoms of hyperthyroidism and decreased FT3 levels, indicating the importance to conduct a thorough history to manage polypharmacy drug overdoses. This case highlights plasmapheresis as an effective treatment modality for thyroid storm. Presentation: No date and time listed |
