Thyroid storm

H1N1 infection-induced thyroid storm

A thyroid storm is a life-threatening exacerbation of thyrotoxicosis, and is usually characterized by hyperthermia, tachycardia, severe agitation and altered mental status. A thyroid storm may be triggered by many causes, including systemic pulmonary infections. Delay in prompt diagnosis leads to high mortality. We present the first case of H1N1 infection triggering a thyroid storm. The delay in diagnosis because of preoccupancy with the H1N1 pandemic may have contributed to the poor outcome. When assessing cases with H1N1 infection, physicians should be more vigilant in order not to miss other important diagnoses.

Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: A case report

BACKGROUND

Thyroid storm is a condition in which multiple organ dysfunction results from failure of the compensatory mechanisms of the body owing to excessive thyroid hormone activity induced by some factors in patients with thyrotoxicosis. While diabetic ketoacidosis (DKA) is an important trigger for thyroid storm, simultaneous development of DKA and thyroid storm is rare.

CASE PRESENTATION

A 59-year-old woman with no history of either diabetes mellitus or thyroid disease presented to our hospital because of developing nausea, vomiting and diarrhea for 2 days. Physical examination showed mild disturbance of consciousness, fever, and tachycardia. There were no other signs of thyrotoxicosis. Laboratory studies revealed elevation of random blood glucose and glycosylated hemoglobin, strongly positive of urine acetone, and metabolic acidosis. Since DKA was diagnosed, we initiated the patient on treatment with administration of insulin and adequate fluid replacement. Although the hyperglycemia and acidosis were immediately relieved, the disturbance of consciousness and tachycardia remained persistent. Levels of FT3 and FT4 were extremely high and TSH was below the detectable limit. TRAb was positive. The thyroid storm score of Burch & Wartofsky was 75/140, and the thyroid storm diagnostic criteria of the Japan Thyroid Association were satisfied. Oral administration of thiamazole, potassium iodide and propranolol resulted in immediate relief of the tachycardia.

DISCUSSION

We encountered a case of thyroid storm associated with Graves' disease covered by DKA. Thyroid storm and DKA are both potentially fatal, and the prognosis varies depending on whether or not these conditions are detected and treated sufficiently early. The thyroid storm diagnostic criteria prepared in 2008 by the Japan Thyroid Association are very simple as compared to the Burch & Wartofsky scoring system for thyroid storm. The Japanese criteria may be useful in the diagnosis of this condition since they enable clinicians to identify a broad range of cases with thyroid storm. When dealing with cases of DKA or thyroid storm, it seems essential to bear in mind the possibility of the coexistence of these two diseases.

Seizure and encephalopathy associated with thyroid storm in children

Thyroid storm with seizures is very rare in children. The authors report 3 children with thyroid storm who had a seizure in the absence of a history of neurologic disease. Acute medical management with propylthiouracil, Lugol's iodine solution, hydrocortisone, and propranolol led to a complete resolution of the symptoms. Patients with thyroid storm may be predisposed to the development of neuropsychiatric change. Early recognition and treatment of thyroid storm are essential to reduce morbidity and mortality from this disorder.

Severe duodenal hemorrhage induced by Lugol's solution administered for thyroid crisis treatment

Lugol's solution is an iodinated agent used for treating thyroid crisis. It is primarily used in diagnostic tests for esophageal diseases. However, Lugol's solution can cause local mucosal injury and hemorrhage. We report, for the first time, a case of 34-year-old man who exhibited severe duodenal hemorrhage induced by Lugol's solution that was used to treat thyroid crisis. The quantity of Lugol's solution used for treating thyroid crisis is much higher than that used for mucosal disease investigation. Clinical practitioners should be aware of gastrointestinal hemorrhage when using Lugol's solution for the treatment of thyroid crisis.

Fetal death due to upper airway compromise complicated by thyroid storm in a mother with uncontrolled Graves' disease: a case report

Introduction

We report an unusual case of upper airway compromise complicated by thyroid storm in a pregnant woman with Graves' disease, ending with the in utero death of the fetus. This complication might have developed due to upper airway edema as a result of poorly controlled hyperthyroidism.

Case presentation

A 41-year-old Turkish woman at 27 weeks' gestation suffering from Graves' disease was referred to our emergency department with a diagnosis of respiratory arrest. She was unconscious and had been intubated. Her laboratory results were compatible with thyrotoxicosis. The patient had suffered from respiratory difficulty for a long time and had stopped using her antithyroid medications after the first trimester of pregnancy. One day before, she had visited an obstetrician because her respiratory distress had increased. At that time, her fetus was still alive. She was given oxygen therapy and then sent home. With a presumptive diagnosis of thyroid storm, she was admitted to the intensive care unit and treated with aggressive medical therapy. The baby was found to be no longer alive and was delivered vaginally after labor induction. The mother was discharged 10 days later with maintenance therapy.

Conclusion

Hyperthyroidism during pregnancy warrants very close attention and should almost always be treated with appropriate antithyroid medications. Maternal respiratory distress in such patients can be an early sign of impending upper airway compromise and thyroid storm, which can endanger the mother and fetus unless prompt and aggressive therapy is initiated.

Atrial fibrillation from thyroid storm

BACKGROUND

Thyroid storm is an often-discussed but rare presentation to emergency departments (EDs). The clinical presentation of a thyroid storm is the result of a hyperthyroid state that may result in significant morbidity or disability, or even death. Typically, patients are aware of their hyperthyroid condition, and may be able to recognize an episode of thyroid storm. However, the first presentation of hyperthyroidism could, in fact, be from thyrotoxic crisis.

OBJECTIVES

To review the presentation of thyroid storm, including tachycardia, hyperpyrexia, agitation, and altered mental status, which can be easily misdiagnosed as drug intoxication.

CASE REPORT

We present the case of an otherwise healthy young adult who was sent to the ED by an outpatient care provider for generalized and vague symptoms of "feeling unwell" that was eventually diagnosed in the ED as thyrotoxic crisis.

CONCLUSION

We use this case to emphasize that thyrotoxic crisis should be at least considered in the differential diagnosis of a patient with this presentation, and to highlight how, even with apparently usual and effective treatments, a patient may still decompensate.

Lithium-induced Hashimoto's encephalopathy: a case report

OBJECTIVE

To report on a patient with Hashimoto's encephalopathy induced by lithium. PATIENT AND INTERVENTIONS: A 61-year-old woman with a type II bipolar disorder and a history of lithium-induced thyrotoxicosis associated with silent thyroiditis was hospitalized to treat a severe major depressive episode. Given long-term treatment with levothyroxine for hypothyroidism that had resulted from silent thyroiditis, endogenous hormone in thyroid follicles was assumed to be minimized by the negative feedback, decreasing risk of recurrent thyrotoxicosis if lithium were restarted.

RESULTS

Lithium clearly relieved the patient's depressive symptoms, but after 40 days encephalopathy developed. Thyrotoxicosis was ruled out, and serum antithyroid antibody titers were elevated. In the cerebrospinal fluid, protein content was substantially elevated and antithyroid antibodies were detected. Encephalopathy resolved dramatically after course of intravenous pulse therapy with methylprednisolone.

CONCLUSIONS

We believe that autoantibodies against antigens shared by the thyroid gland and the brain were induced by exposure to lithium, causing the patient to develop Hashimoto's encephalopathy.

Abdominal pain and multi-organ dysfunction syndrome in a young woman

Thyroid storm is a rare but life-threatening condition caused by exaggerated thyrotoxic manifestations. Untreated thyroid storm is fatal, and the case fatality rate is 21% to 30%. The most important clinical management in thyroid storm is early recognition and treatment. We present the case of a previously healthy young woman in whom suspected gastrointestinal tract sepsis complicated by multi-organ dysfunction syndrome masked the major symptomatology of thyroid storm. This patient highlights the importance of a high clinical suspicion for potentially life-threatening conditions, such as thyroid storm, even in the absence of clinical clues (exophthalmos, lid lag, and goiter) or a history of thyrotoxicosis.

Feline Thyroid Storm

Thyroid storm is a syndrome described in human medicine to define a multisystemic disorder resulting from organ exposure to excessive levels of thyroid hormone. This form of acute thyrotoxicosis, although uncommon, can be life threatening and is a significant cause of mortality in human emergency rooms. Although thyroid storm is a well-recognized clinical entity in human medicine, it has not been described in veterinary medicine. This article discusses the human syndrome and defines a similar syndrome in hyperthyroid veterinary patients. The clinical signs of and treatment modalities for feline thyroid storm are also presented.

Thyrotoxicosis and thyroid storm

Thyroid storm represents the extreme manifestation of thyrotoxicosis as a true endocrine emergency. Although Grave's disease is the most common underlying disorder in thyroid storm, there is usually a precipitating event or condition that transform the patient into life-threatening thyrotoxicosis. Treatment of thyroid storm involves decreasing new hormone synthesis, inhibiting the release of thyroid hormone, and blocking the peripheral effects of thyroid hormone. This multidrug, therapeutic approach uses thionamides, iodine, beta-adrenergic receptor antagonists, corticosteroids in certain circumstances, and supportive therapy. Certain conditions may warrant the use of alternative therapy with cholestyramine, lithium carbonate, or potassium perchlorate. After the critical illness of thyroid storm subsides, definitive treatment of the underlying thyrotoxicosis can be planned.

Hyperthyroidism

The clinical spectrum of hyperthyroidism varies from asymptomatic,subclinical hyperthyroidism to the life-threatening "thyroid storm". Hyperthyroidism is a common form of thyroid disease that mimics many of the common complaints in the emergency department. The diagnosis of hyperthyroidism is often challenging due to the multitude of physical and even psychiatric complaints. Recognition and treatment by emergency physicians of severe hyperthyroidism is critical and can be life saving.

Endocrine emergencies

Diabetic and endocrine emergencies are traditionally treated by the acute medical admitting team or accident and emergency department staff. Most will see diabetic emergencies on a regular basis, as they are common and both type 1 and type 2 disease are increasing in prevalence. Diabetic emergencies are usually easily treated and the patients discharged. However, it is vital not to become complacent as these disorders can lead to death. It is particularly important to follow local guidance and to involve the diabetes team both during and after each episode. Recently it has become clear that about 30% of patients admitted with acute coronary syndrome (including infarction) have either diabetes or "stress hyperglycaemia"; evidence suggests that these patients should be treated not only as a cardiac emergency but also as a diabetic one. Thus, every patient with acute coronary syndrome or acute myocardial infarction needs diabetes to be excluded. The other endocrine emergencies are less common, but in some ways more important simply because of their rarity. A high level of suspicion is often required to make a diagnosis, although some, such as myxoedema coma, are usually obvious. Treatment must be started before the diagnosis can be confirmed. Guidance on making the diagnosis and initiating treatment should be made available on the local NHS intranet for non-endocrinologists to access; and where possible expert advice made available by telephone. The basic management steps in the common diabetic and endocrine emergencies are outlined; this is not a complete list, but rather an insight for those involved in non-selected emergency admissions.

Thyrotoxic crisis induced by cytotoxic chemotherapy

Thyroid storm is a rare and life-threatening medical emergency. We report a young lady with Graves' disease and acute myeloid leukaemia who developed thyrotoxic crisis following an induction course of chemotherapy given for the treatment of acute leukaemia. After successful management of her leukaemia and thyroid disease, she received an autologous bone marrow transplantation.

Juvenile thyrotoxicosis; can we do better?

Thyrotoxicosis remains a frustrating condition for the young person, family, and health professionals involved. The associated symptoms do not always suggest thyroid disease and patients can be unwell for many months before the diagnosis is made. The antithyroid drug regimen used to treat children and adolescents with thyrotoxicosis varies from one unit to another and yet the potentially life threatening side effects and remission rates post-treatment may be related to the regimen used. Most patients with thyrotoxicosis will need many years of drug therapy if the thyroid gland is not removed surgically or destroyed by radioiodine. Even "definitive" treatment will typically necessitate thyroxine replacement for life.

Thyroid Storm Induced by Strangulation

Thyroid storm most often occurs in patients with known thyrotoxicosis. This report discusses a severe case of thyroid storm developing as a direct result of strangulation in a patient without a preexisting history of thyroid disease. Classification and treatment of this entity are discussed.

Thyroid Storm and Ventricular Tachycardia

A 34-year-old woman was brought to our emergency department because of sudden loss of consciousness. Ventricular tachycardia and fibrillation were noted on electrocardiographic monitoring and reverted to sinus rhythm after repeated defibrillation. She was treated as a case of thyroid storm. Although tachycardia and fever normalized after 2 days, she remained comatose and died. This is an unusual case because the patient's initial presentation was cardiac arrest without previous history of cardiac disease. To our knowledge, this is the first reported case where ventricular tachyarrhythmia was the initial presenting sign of thyroid storm.

Hyperthyroidism in pregnancy

Graves' disease may complicate the course of pregnancy; pregnancy on the other hand may alter the natural course of the disease. It is imperative for women of childbearing age affected by the disease to be informed about the potential maternal and fetal problems if the condition is not properly managed. Preconception control in women with diabetes has resulted in a dramatic decrease in the number of perinatal complications. The same approach should be encouraged for women with thyroid diseases. Ideally, the women suffering from hyperthyroidism or any other thyroid disease should be metabolically compensated at time of conception-the need for contraception until the disease is controlled should be openly discussed. A multidisciplinary approach by a health care team is of paramount importance during pregnancy, with the involvement of the obstetrician, perinatologist, endocrinologist, neonatologist, pediatrician and anesthesiologist. In many situations the assistance of social workers, nutritionists, and other health care professionals may be needed. The future mother and her family should be aware of the potential complications for both mother and her offspring if proper management guidelines are not carefully followed.

Critical issues in endocrinology

Endocrine emergencies are commonly encountered in the ICU. This article focuses on several important endocrine emergencies, including diabetic hyperglycemic states, adrenal insufficiency, myxedema coma, thyroid storm, and pituitary apoplexy. Other endocrine issues that are related to intensive care, such as intensive insulin therapy, relative adrenal insufficiency, and thyroid function test abnormalities are also covered in detail.

Cardiovascular manifestations of thyroid storm: a case report

We present a case of thyroid storm manifesting as supraventricular tachycardia with cardiopulmonary dysfunction. Our patient presented with severe cardiopulmonary symptoms (tachycardia, respiratory distress, and pulmonary edema) refractory to standard medical treatment. When the diagnosis of thyroid storm was made and proper treatment initiated, our patient had a prompt and appropriate response.

Report of a Rare Case of Trauma-Induced Thyroid Storm

Thyroid storm is a potentially life-threatening endocrinologic emergency characterized by an exacerbation of a hyperthyroid state. Several inciting factors can instigate the conversion of thyrotoxicosis to thyroid storm; trauma is one such trigger, but it is rare. Patients with thyroid storm can manifest fever, nervous system disorders, gastrointestinal or hepatic dysfunction (e.g., nausea, vomiting, diarrhea, and/or jaundice), and arrhythmia and other cardiovascular abnormalities. Treatment of thyroid storm is multimodal and is best managed by the endocrinologist and medical intensivist. Initial medical and supportive therapies are directed at stabilizing the patient, correcting the hyperthyroid state, managing the systemic decompensation, and treating the underlying cause. Once this has been achieved, definitive treatment in the form of radioactive ablation or surgery should be undertaken. We describe a case of thyroid storm in a young man that was precipitated by a motor vehicle accident.

Perioperative management of selected endocrine disorders

Anesthesiologists routinely encounter patients with endocrine disorders. Good perioperative outcome depends on preoperative identification, risk stratification and optimization of the patients' endocrinopathies and their sequelae; intraoperative control of metabolic and physiological parameters; and appropriate postoperative pain management, stress modulation, and evaluation of neurological, cardiovascular, and renal function.

Drug therapy for hyperthyroidism in pregnancy: safety issues for mother and fetus

Hyperthyroidism (thyrotoxicosis) in pregnancy and the child bearing years is usually attributable to Graves' disease. This is an autoimmune condition in which thyroid-stimulating immunoglobulins (TSI) cause hyperthyroidism. As a rule, pregnancy complicates the management of hyperthyroidism, rather than vice versa. However, patients who remain thyrotoxic during pregnancy are at increased risk of maternal and fetal complications, particularly miscarriage and stillbirth. Therefore, bodyweight loss, eye signs and a bruit over the thyroid gland in a pregnant woman warrant thyroid investigation. Investigations should include measurement of serum free thyroid hormone levels [free thyroxine (T4) and free triiodothyronine (T3)] rather than total T4 and T3 levels, because total T4 and T3 levels may be raised in euthyroid pregnancies due to the presence of increased levels of thyroxine binding globulin (TBG). By 20 weeks' gestational age, the fetal thyroid is fully responsive to TSI and to antithyroid drugs. Maternal T4 and T3 and thyrotropin pass across the placenta in small and decreasing amounts as gestation progresses, but thyrotropin releasing hormone, TSI, antithyroid drugs, iodides and beta-blockers are readily transferred to the fetus from the mother. Hyperthyroidism is usually treated throughout pregnancy with an antithyroid drug, preferably propylthiouracil. The smallest dose which controls the disease is given with careful monitoring of free T4 and T3 levels to minimise the risk of fetal hypothyroidism and goitre. Bilateral subtotal thyroidectomy may be an option for a small number of patients with hyperthyroidism in pregnancy.

Thyrotoxicosis as a predisposing factor for cerebral venous thrombosis

Thyroid storm is a rare and life-threatening complication of untreated thyrotoxicosis. A number of neurological complications have been described in association with thyrotoxicosis. We report the case of a 28-year-old woman with a thyroid storm on the basis of Graves' disease and probably triggered by a surgical procedure. She developed cerebral venous thrombosis (CVT) of the left transverse and rectus sinus with a venous infarction of the left thalamus. Except for an increased factor VIII clotting activity there were no thrombophilic abnormalities. Similar cases have been described in the literature and the reported incidence of the combination of CVT and thyrotoxicosis is significantly higher than expected by chance alone (0.1 x 10(-6) per year vs. 0.0032 x 10(-6)/year). This case is consistent with the assumption that thyrotoxicosis, probably through a factor VIII-mediated hypercoagulability, may be a predisposing factor for the development of CVT.

Trauma and thyroid-induced tachycardia

Excluding a source of hemorrhage after blunt trauma in a patient who presents with a sustained tachycardia can be challenging. This report is of two trauma patients presenting with undiagnosed thyrotoxicosis. Trauma-triggered thyrotoxicosis is rarely reported in the literature. The confusing presentation, the laboratory analysis, and the response to therapeutic intervention are reviewed.

Endocrinologic and metabolic complications in the intensive care unit

Critical illness provides major stresses on all body systems, including those serving important regulatory functions. Endocrinologic and metabolic abnormalities are common on presentation and during hospitalization in the intensive care unit. Some of these abnormalities are the focus of this article. The authors review abnormalities of the adrenal and thyroid glands and in the metabolism of glucose, and include a brief review of abnormalities of sodium and calcium metabolism.

Differential diagnosis of thyroid crisis and malignant hyperthermia in an anesthetized porcine model

The intra-operative differential diagnosis between thyroid crisis and malignant hyperthermia can be difficult. Also stress alone can trigger MH. The purposes of this study were: 1) to investigate the metabolic and hemodynamic differences between thyroid crisis and MH, 2) determine how thyroid crisis affects the development of MH, and 3) determine if the stress of thyroid crisis can trigger MH in susceptible individuals. We studied MH susceptible and normal swine. Two groups of animals (MH susceptible and normal) were induced into thyroid crisis (critical core hyperthermia, sustained tachycardia and increase in oxygen consumption) by pretreatment with intraperitoneal triiodothyronine (T3) followed by large hourly intravenous injections of T3. Two similar groups were given intravenous T3 but no pretreatment. These animals did not develop thyroid crisis and served as controls. Thyroid crisis did not result in metabolic changes or rigidity characteristic of an acute episode of MH. When the animals were subsequently challenged with MH triggering agents (halothane plus succinylcholine) dramatic manifestations of fulminant MH episodes (acute serious elevation in exhaled carbon dioxide, arterial CO2, rigidity and acidemia) were noted only in the MH susceptible animals. Although thyroid crisis did not trigger MH in the susceptible animals it did decrease the time to trigger MH (14.1 +/- 7.2 minutes versus 47.2 +/- 17.7 minutes, p < 0.01) in susceptible animals. Hormone induced elevations in temperature and possibly other unidentified factors during thyroid crisis may facilitate the triggering of MH following halothane and succinylcholine challenge.

Thyroid storm precipitated by trauma

A 21-year-old woman presented to the emergency department complaining of head, neck, and abdominal pain after being assaulted. She denied a previous history or significant symptoms of hyperthyroidism. The physical examination was remarkable for lethargy, low-grade fever, tachycardia, facial abrasions, swelling of the anterior neck, and a tremor. A diagnosis of thyroid storm was made. An extensive work up excluded other causes of the patient's tachycardia, altered mental status, and neck swelling. A review of the clinical features and management of thyroid storm is presented. Relatively minor trauma can be a precipitating event for thyroid storm.