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Initiation of levothyroxine in a patient with hypothyroidism inducing adrenal crisis requiring VA ECMO: a tale of preventable disaster
  1. Mandip Singh Kang1,
  2. Charnjeet Singh Sandhu1,
  3. Natasha Singh1 and
  4. Timothy Evans2
  1. 1 Internal Medicine, UCSF, Fresno, California, USA
  2. 2 Pulmonary Medicine and Critical Care, UCSF, Fresno, California, USA
  1. Correspondence to Dr Mandip Singh Kang, MKang{at}


A 31-year-old man with a recent diagnosis of hypothyroidism presented to the emergency department as a transfer from the clinic for severe hypotension and hypoglycaemia. The patient endorsed a 2-week history of severe fatigue, weight loss, nausea and non-bloody emesis. He was aggressively hydrated and vasopressors were initiated. Despite these measures, the patient remained hypotensive and went into pulseless electrical activity. Return of spontaneous circulation was achieved via advanced cardiac life support protocol, and venous arterial extracorporeal membrane oxygenation (ECMO) was initiated. On day 3 of hospitalisation, the patient was weaned off ECMO support, and subsequent autoimmune work-up confirmed the diagnosis of autoimmune polyglandular syndrome type 2 with positive antiperoxidase antibodies (267 IU/mL), supporting the diagnosis of Hashimoto’s thyroiditis.

  • general guidance on prescribing
  • resuscitation
  • endocrinology
  • adult Intensive care
  • medical management

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  • Contributors CSS admitted and provided care for the patient in the case report. MSK worked on the planning, discussion and acquisition of the data involved in the case report. NS provided care for the patient as the senior resident, and contributed to the case report by providing insight into the conception and overall design. TE provided guidance on the critical care component of the discussion and insight into the VA ECMO intervention that was implemented. All authors were involved in editing of the case report, along with equal contribution to the content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.

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