The apprehension caused by an unplanned use of lugol's iodine

Introduction: Lugol's iodine is used for 10 days prior to thyroidectomy to improve hyperthyroidism, reduce vascularity, and blood loss It is also used for severe thyrotoxicosis and thyroid storm We present a case of hyperthyroidism where we focus on certain management issues Case Description: A 50-year-old lady presented on April 2020 with a relapse of Graves' disease Her first episode was treated from August 2015 to April 2019 with propylthiouracil after having had adverse effects with carbimazole In April 2020, freeT4 was 32 9 pmol/L (11-23) and TSH was 100, FreeT3 34 9 pmol/L (3 1-6 8), and TSH <0 01 and her Burch-Wartofsky Point Scale (BWPS) score for thyroid storm was 25 With the provisional diagnosis of impending thyroid storm on a background of poor clinical response to propylthiouracil, lugol's iodine was initiated with an intention to arrange thyroidectomy in 10-14 days as the definitive treatment However, the feasibility of having a surgery during the pandemic was not considered at the time of initiation During her stay, her thyroid profile started to improve within 3 days of initiating lugol's iodine (Free T4 67 6, TSH <0 01) and within 10 days near normal thyroid function were achieved (freeT4-26 0, freeT3-7 03) She was referred to the ENT team for consideration of an emergency surgery After repeated desperate communications, we succeeded to convince the ENT team to accept for emergency thyroidectomy Still due to unforeseen circumstances related to Covid and due to interdepartmental miscommunications, the surgery happened only 16 days after lugol's iodine initiation Clinical discussion: Lugol's iodine blocks the release of thyroid hormones This Wolff-Chaikoff effect starts within 24-48 hours and last until 10-14 days, after which escape occurs which might worsen hyperthyroidism (after 21 days) In our case, lugol's iodine should have been started after assessing feasibility for thyroidectomy