A 31-year-old woman presents with fever 39.5 degrees C, delirium, heart rate 150/min, and a diffusely enlarged tender thyroid. Free T4 is markedly elevated. Which initial drug combination is most appropriate?

• A Lugol iodine first, followed one hour later by propylthiouracil
• B Propylthiouracil plus propranolol, with iodine added at least one hour after the thionamide ✓
• C Methimazole plus atenolol, with radioiodine ablation planned within 48 hours
• D Hydrocortisone alone while awaiting thyroid function confirmation

Explanation

Thyroid storm is treated with a beta blocker for adrenergic symptoms, a thionamide to halt new hormone synthesis, iodine to block release, and glucocorticoid. Propylthiouracil is preferred over methimazole in storm because it also blocks peripheral T4 to T3 conversion. Iodine must be delayed at least one hour after the thionamide; giving it first provides substrate for new hormone synthesis and can worsen the storm.

Reference: Williams Textbook of Endocrinology, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.