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Saleem M, Sethi SM, Ali A, Kiran Z. Metastatic choriocarcinoma in a young woman presenting as thyroid storm: a case report. J Med Case Rep 2021; 15:519. [PMID: 34686220 PMCID: PMC8536474 DOI: 10.1186/s13256-021-03123-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background Thyroid storm is an endocrine emergency and life-threatening condition discovered in 1926. There is no specific laboratory parameter that can differentiate or distinguish between thyroid storm and primary hyperthyroidism. Diagnosis is made on a clinical scoring system, including the Burch–Wartofsky point scale and Japanese Thyroid Association scoring system. The management is early diagnosis, immediate initiation of anti-thyroid medications, intensive care monitoring, and prevention of multiorgan failure. Case presentation A 30-year-old Pakistani female presented with complaint of headache, vomiting, and generalized weakness for 3 weeks. She had an episode of seizure-like activity at home, and so was rushed to the emergency department. A detailed thyroid examination revealed a soft, nontender gland with no enlargement or bruit and no exophthalmos. Her thyroid-stimulating hormone was extremely low, with high free triiodothyronine and thyroxine. Thyroglobulin was 425 ng/ml (normal reference range ≤ 55 ng/ml), and thyroid-stimulating hormone receptor antibody was 0.87 IU/L (normal reference range 0–1.75 IU/L). She had high levels of beta-human chorionic gonadotropin hormone on initial presentation. Transvaginal ultrasound showed no intrauterine pregnancy, but an echogenic focus was found adherent to the right ovary with no vascularity. With the chief complaint of headache, she underwent magnetic resonance imaging of the brain that showed multiple scattered hemorrhagic lesions in supratentorial and infratentorial brain parenchyma that were highly suspicious for metastases. Computed tomography scan of the chest, abdomen, and pelvis revealed multiple neoplastic lesions in the lung, liver, spleen, and kidneys. A Tru-Cut liver biopsy showed linear cores of liver tissue with metastatic carcinoma with morphological features consistent with choriocarcinoma. Our patient scored 65 on the Burch–Wartofsky point scale. As per the Japanese Thyroid Association scoring system, our patient met the criteria for a “definite thyroid storm.” She had initiated propranolol to achieve adequate control of her heart rate and dexamethasone. Carbimazole was started to control her thyroid function. Her thyroid function after 2 weeks of treatment showed significant improvement. Methotrexate and etoposide were given for choriocarcinoma. She made a good recovery and was discharged home. She will undergo rehabilitation along with ongoing chemotherapy (methotrexate and etoposide weekly till beta-human chorionic gonadotropin levels normalize). Unless her source of beta-human chorionic gonadotropin is carefully under control, she will continue to take anti-thyroid medications. Conclusion Choriocarcinoma is not only associated with hyperthyroidism but can induce thyroid storm. Beta-human chorionic gonadotropin is directly associated with promoting thyroid dysfunction. Patients with gestational trophoblastic disease should be under close surveillance to prevent thyroid storms.
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Affiliation(s)
| | - Sher M Sethi
- The Aga Khan University Hospital, Karachi, Pakistan.
| | - Abrar Ali
- The Aga Khan University Hospital, Karachi, Pakistan
| | - Zareen Kiran
- The Aga Khan University Hospital, Karachi, Pakistan
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Nogami M, Constantine S, Sai S. Neurological and gastrointestinal symptoms as an initial presentation of pediatric thyroid storm: report of three cases. J Pediatr Endocrinol Metab 2021; 34:1197-1200. [PMID: 34162035 DOI: 10.1515/jpem-2021-0219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Thyroid storm (TS) is a rare but life-threatening condition caused by decompensated hyperthyroidism. There is no consensus on how to diagnose pediatric TS. We report three pediatric cases of TS presenting with central nervous system (CNS) and gastrointestinal (GI) symptoms as the initial presentation of Graves' disease. CASE PRESENTATION They were previously healthy adolescents without family history of thyroid disease. CNS symptoms varied from agitation to coma. GI symptoms included abdominal pain, vomiting, and diarrhea. Their laboratory studies revealed thyrotoxicosis and positive result of thyroid-stimulating antibody (TSAb). They were admitted to the intensive care unit (ICU) and received the combination of an antithyroid drug, Lugol's solution, a beta antagonist, and hydrocortisone. The most severe case was a 13 year-old Japanese girl who presented with loss of consciousness and hemodynamic shock. She died after 5 days of intensive treatment. CONCLUSIONS Pediatricians should consider TS in the differential diagnosis when a patient exhibits both CNS and GI symptoms.
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Affiliation(s)
- Masao Nogami
- Department of Pediatrics, Teine Keijinkai Hospital, Sapporo, Japan
| | | | - Shuji Sai
- Department of Pediatrics, Teine Keijinkai Hospital, Sapporo, Japan
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Chrgondi M, Billa RD, Chacham S, Gurnurkar S. Unusual Etiology of Hypercalcemia in an Adolescent With Acute Gastroenteritis. Cureus 2021; 13:e16483. [PMID: 34430099 PMCID: PMC8372673 DOI: 10.7759/cureus.16483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/05/2022] Open
Abstract
We present the report of an adolescent female who presented with acute gastroenteritis, weight loss, and hypercalcemia. Further evaluation revealed hyperthyroidism to be the cause of hypercalcemia. Treatment of hyperthyroidism successfully corrected the hypercalcemia in our index case.
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Affiliation(s)
- Madhuradhar Chrgondi
- Pediatrics/Critical Care Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA
| | | | - Swathi Chacham
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Shilpa Gurnurkar
- Pediatric Endocrinology, Nemours Children's Hospital, Orlando, USA
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54
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Lee JSG, Brown IE, Semrad AM, Zeki AA. Getting around the gut: a unique management challenge of thyroid storm precipitated by amphetamine-associated duodenal ischaemia leading to compromised enteric absorption. BMJ Case Rep 2021; 14:e238889. [PMID: 34413029 PMCID: PMC8378395 DOI: 10.1136/bcr-2020-238889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/04/2022] Open
Abstract
Thyroid storm is a rare, life-threatening endocrine emergency with a high mortality rate of up to 30%. We present a unique management challenge of a critically ill patient who developed thyroid storm in the setting of a duodenal perforation from amphetamine-associated non-occlusive mesenteric ischaemia. The diagnosis of 'thyroid storm' was made based on clinical criteria and a Burch-Wartofsky score of 100. During emergent exploratory laparotomy, a 1 cm duodenal perforation with surrounding friable tissue was found and repaired. Intraoperatively, a nasogastric tube was guided distal to the area of perforation to allow for enteric administration of medications, which was critical in the setting of thyroid storm. Therapeutic plasma exchange achieved biochemical control of our patient's thyroid storm but ultimately did not prevent in-hospital mortality.
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Affiliation(s)
- Jin Sol Gene Lee
- Internal Medicine, University of California Davis, Sacramento, California, USA
| | - Ian Elliott Brown
- Surgery, University of California Davis, Sacramento, California, USA
| | - Alison M Semrad
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of California Davis, Sacramento, California, USA
- Endocrinology, Tahoe Forest Health System, Tahoe, California, USA
| | - Amir A Zeki
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California Davis, Sacramento, California, USA
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55
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Wu L, Wang W, Leng Q, Tang N, Zhou N, Wang Y, Wang DW. Focus on Autoimmune Myocarditis in Graves' Disease: A Case-Based Review. Front Cardiovasc Med 2021; 8:678645. [PMID: 34307494 PMCID: PMC8292634 DOI: 10.3389/fcvm.2021.678645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/02/2021] [Indexed: 12/15/2022] Open
Abstract
The manifestations of hyperthyroidism-related myocardial damage are multitudinous, including arrhythmia, dilated cardiomyopathy, valvular diseases, and even cardiogenic shock. Acute myocarditis induced by thyrotoxicosis had been reported in a few studies. However, attention on its prevalence and underlying mechanisms is sorely lacking. Its long-term harm is often ignored, and it may eventually develop into dilated cardiomyopathy and heart failure. We report a case of Graves' disease with a progressive elevation of hypersensitive cardiac troponin-I at several days after discontinuation of the patient's anti-thyroid drugs. Cardiac magnetic resonance imaging (CMRI) showed inflammatory edema of some cardiomyocytes (stranded enhanced signals under T2 mapping), myocardial necrosis (scattered enhanced signals under T1 late gadolinium enhancement) in the medial and inferior epicardial wall, with a decreased left ventricular systolic function (48%), which implied a possibility of acute myocarditis induced by thyrotoxicosis. The patient was then given a transient glucocorticoid (GC) treatment and achieved a good curative effect. Inspired by this case, we aim to systematically elaborate the pathogenesis, diagnosis, and treatment of hyperthyroidism-induced autoimmune myocarditis. Additionally, we emphasize the importance of CMRI and GC therapy in the diagnosis and treatment of hyperthyroidism-related myocarditis.
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Affiliation(s)
- Lujin Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Huazhong University of Science and Technology, Wuhan, China
| | - Qianru Leng
- Division of Cardiology, Department of Internal Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Huazhong University of Science and Technology, Wuhan, China
| | - Nana Tang
- Nursing Teaching Office of Internal Medicine, Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | - Ning Zhou
- Division of Cardiology, Department of Internal Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Huazhong University of Science and Technology, Wuhan, China
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Huazhong University of Science and Technology, Wuhan, China
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56
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Yu H, Zhou A, Liu J, Tang Y, Yuan Q, Man Y, Xiang L. Management of systemic risk factors ahead of dental implant therapy: A beard well lathered is half shaved. J Leukoc Biol 2021; 110:591-604. [PMID: 34231923 DOI: 10.1002/jlb.6mr0621-760rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023] Open
Abstract
As the most successful therapy for missing teeth, dental implant has become increasingly prevalent around the world. A lot of papers have reported diverse local risk factors affecting the success and survival rate of dental implants, either for a short or a long period. However, there are also many types of systemic disorders or relatively administrated medicine that may jeopardize the security and success of dental implant treatment. Additionally, the coronavirus disease 2019 pandemic also poses a challenge to dental implant clinicians. Some of these risk factors are clinically common but to some extent unfamiliar to dentists, thus optimal measurements are often lacking when they occur in dental clinics. In this review, we analyze potential systemic risk factors that may affect the success rate of dental implants. Some of them may affect bone mineral density or enhance the likelihood of local infection, thus impeding osseointegration. Others may even systemically increase the risk of the surgery and threaten patients' life. In order to help novices receive high-risk patients who need to get dental implant treatment in a more reasonable way, we accordingly review recent research results and clinical experiments to discuss promising precautions, such as stopping drugs that impact bone mineral density or the operation, and addressing any perturbations on vital signs.
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Affiliation(s)
- Hui Yu
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Anqi Zhou
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jiayi Liu
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yufei Tang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Quan Yuan
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yi Man
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Lin Xiang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,Department of Oral Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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57
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Rao AN, Al-Ward RY, Gaba R. REPLY TO: What is the effect of obesity on the natriuretic peptide pathway? AACE Clin Case Rep 2021; 7:360-362. [PMID: 34250225 PMCID: PMC8253658 DOI: 10.1016/j.aace.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective Thyroid storm is a severe exacerbation of thyrotoxicosis that can cause significant morbidity and mortality. The emergence of the novel coronavirus (SARS-CoV-2) that originated in Wuhan, China has become a worldwide pandemic. We present the first documented case of thyroid storm (as defined by the Burch-Wartofsky criteria) in a patient positive for COVID-19. Methods Laboratory and diagnostic studies including thyroid function tests, thyroid antibody testing, SARS-CoV-2 nasopharyngeal PCR testing, and thyroid ultrasound were performed. Results A 25-year-old female presented to the hospital with dry cough, dyspnea, palpitations, weight loss, diarrhea, and anxiety. Physical exam revealed exophthalmos with proptosis and chemosis, tachycardia, diffusely enlarged goiter with bruit, and fine tremor. Laboratory results demonstrated a thyroid-stimulating hormone (TSH) <0.01 mIU/L (normal range 0.44-5.3 mIU/L), free thyroxine (FT4) 5.34 ng/dL (normal range 0.64-1.42 ng/dL), total triiodothyronine (T3) 654 ng/dL (normal range 87-178 ng/dL), and thyroid-stimulating immunoglobulin 7.18 IU/L (normal range 0.00-0.55 IU/L). Thyroid ultrasound revealed heterogeneous echotexture with increased vascularity. Nasopharyngeal COVID-19 testing was positive. She was treated promptly with propranolol, propylthiouracil, and hydrocortisone with improvement in symptoms, and later switched to methimazole. Her COVID-19 course was uncomplicated, and she left the hospital with minimal residual respiratory symptoms. Conclusion Thyroid storm is one of the more prevalent endocrine emergencies and is often precipitated by an acute event like infection. Patients with thyroid storm may have concomitant SARS-CoV-2 infection that could influence the clinical course and severity of the disease. In patients with symptoms of thyrotoxicosis along with respiratory symptoms, clinicians should consider checking a COVID-19 test.
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Key Words
- AST/ALT, aspartate amino transferase/amino alanine transferase
- BMI, body mass index
- BMP, basic metabolic panel
- CBC, complete blood count
- CNS, central nervous system
- COVID-19, coronavirus disease 2019
- ECG, electrocardiogram
- FT4, free thyroxine
- RNA, ribonucleic acid
- RT- PCR, reverse transcription polymerase chain reaction
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- T3, triiodothyronine
- T4, thyroxine
- TSH, thyroid-stimulating hormone
- WBC, white blood cell
- bpm, beats per minute
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Affiliation(s)
- Angela N Rao
- Baylor College of Medicine, Department of Internal Medicine
| | - Ruaa Y Al-Ward
- Baylor College of Medicine, Department of Internal Medicine, Section of Endocrinology
| | - Ruchi Gaba
- Baylor College of Medicine, Department of Internal Medicine, Section of Endocrinology
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58
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Abera BT, Abera MA, Berhe G, Abreha GF, Gebru HT, Abraha HE, Ebrahim MM. Thyrotoxicosis and dilated cardiomyopathy in developing countries. BMC Endocr Disord 2021; 21:132. [PMID: 34182968 PMCID: PMC8240202 DOI: 10.1186/s12902-021-00796-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Thyrotoxicosis is the state of thyroid hormone excess. But, in sub-Saharan Africa (SSA), specifically Northern Ethiopia, scientific evidence about thyrotoxicosis and its cardiac complications like dilated cardiomyopathy is limited. Therefore, this study aimed to explore the thyrotoxicosis presentation and management and identify factors associated with dilated cardiomyopathy in a tertiary hospital in Northern Ethiopia. METHODS An institution-based cross-sectional study was conducted in Ayder Comprehensive Specialized Hospital from 2017 to 2018. Data from 200 thyrotoxicosis cases were collected using a structured questionnaire. After describing variables, logistic regression was conducted to identify independent predictors of dilated cardiomyopathy. Statistical significance was declared at p < 0.05. RESULTS Mean age at presentation of thyrotoxicosis was 45 years and females accounted for 89 % of the cases. The most frequent etiology was multinodular toxic goiter (51.5 %). As well, the most common symptoms and signs were palpitation and goiter respectively. Thyroid storm occurred in 6 % of the cases. Out of 89 patients subjected to echocardiography, 35 (39.3 %) of them had dilated cardiomyopathy. And, the odds of dilated cardiomyopathy were higher in patients who had atrial fibrillation (AOR = 15.95, 95 % CI:5.89-38.16, p = 0.001) and tachycardia (AOR = 2.73, 95 % CI:1.04-7.15, p = 0.040). All patients took propylthiouracil and 13.0 % of them experienced its side effects. Concerning β-blockers, propranolol was the most commonly (78.5 % of the cases) used drug followed by atenolol (15.0 %). Six patients underwent surgery. CONCLUSIONS In developing countries like Ethiopia, patients with thyrotoxicosis have no access to methimazole which is the first-line anti-thyroid drug. Besides, they greatly suffer from dilated cardiomyopathy (due to late presentation) and side effects of propylthiouracil. Therefore, we recommend that patients should get adequate health information about thyrotoxicosis and anti-thyroid drugs including their side effects. Additionally, hospitals and other concerned bodies should also avail of TSH tests and methimazole at an affordable cost. Furthermore, community awareness about iodized salt and iodine-rich foods should be enhanced.
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Hodgson JA, Pittman BP, Solomon JB, Elrefai A, Kristobak BM. Postoperative Thyroid Storm After Evacuation of a Complete Hydatidiform Mole: A Case Report. A A Pract 2021; 15:e01495. [PMID: 34170868 DOI: 10.1213/xaa.0000000000001495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gestational trophoblastic disease can lead to excess thyroid hormone release and rarely, thyroid storm. We present a case of complete molar pregnancy with hyperthyroidism that was not identified or treated before surgical evacuation of uterine contents. Untreated hyperthyroidism preoperatively led to unanticipated thyroid storm immediately after emergence from anesthesia. It is important for anesthesia providers to recognize the link between gestational trophoblastic disease and thyrotoxicosis, and appreciate the severe consequences than can occur if left untreated. Anesthesia providers should strongly consider preoperative consultation and treatment. Being prepared to treat intraoperative symptoms and thyroid storm is paramount.
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Affiliation(s)
- John A Hodgson
- From the Department of Anesthesiology, Inova Fairfax Hospital, Falls Church, Virginia.,the Department of Anesthesiology Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Benjamin P Pittman
- the Department of Anesthesiology Walter Reed National Military Medical Center, Bethesda, Maryland
| | - James B Solomon
- From the Department of Anesthesiology, Inova Fairfax Hospital, Falls Church, Virginia.,the Department of Anesthesiology Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Ahmed Elrefai
- From the Department of Anesthesiology, Inova Fairfax Hospital, Falls Church, Virginia
| | - Benjamin M Kristobak
- the Department of Anesthesiology Walter Reed National Military Medical Center, Bethesda, Maryland
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Kositanurit W, Kittipibul V, Srichomkwun P, Boonyaratavej S, Puwanant S. Clinical phenotypes and prognosis of thyrotoxic heart failure and cardiomyopathy in patients hospitalized for acute heart failure. ESC Heart Fail 2021; 8:2776-2783. [PMID: 33932131 PMCID: PMC8318454 DOI: 10.1002/ehf2.13347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/18/2022] Open
Abstract
Background We sought to examine clinical characteristics and outcomes in patients hospitalized for acute heart failure (HF) and thyrotoxicosis. Methods Patients with thyrotoxic HF were compared with age and gender‐matched patients hospitalized for acute HF (controls). Thyr‐HF was defined by the Framingham criteria for HF and clinical hyperthyroidism. Thyrotoxic cardiomyopathy was defined as left ventricular ejection fraction (LVEF) < 55%. Results Of 11 109 consecutive patients hospitalized for acute HF between 1 January 2002 and 1 January 2017, 92 patients (0.8%) had thyrotoxic HF. Clinical and echocardiographic data were available in 87 patients (age 51 ± 16 years; 74% female), representing the study population. Compared with controls, patients with Thyr‐HF had a smaller body surface area (BSA), a higher LVEF, a lower LV end‐diastolic diameter, a higher tricuspid annular plane systolic excursion (TAPSE), higher blood pressure, higher heart rate, and were more likely to have right‐sided HF at presentation (P < 0.01 for all). The survival rate among patients with thyrotoxic HF was higher than the control group (HR: 4.3; 95% CI: 2.1–9.5). Fifty‐eight percent of patients with thyrotoxic HF had thyrotoxic cardiomyopathy. In multivariate analysis, TAPSE (OR = 46; 95% CI: 1.04–2008.20; P = 0.047) and leukocytosis (OR = 16; 95% CI 1.01–259.39; P = 0.049) correlated with thyrotoxic cardiomyopathy. LV recovery was observed in 69% of these patients. Conclusions Thyrotoxic HF was uncommon among patients hospitalized for acute HF. However, after definitive therapy, these patients had a more favourable prognosis than those hospitalized for acute HF without thyrotoxic HF. Clinical phenotypes of thyrotoxic HF include small BSA, middle‐aged female, HF‐pEF, and right‐sided HF. Thyrotoxic cardiomyopathy affected over half of the patients with thyrotoxic HF with a two‐third recovery rate.
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Affiliation(s)
- Weerapat Kositanurit
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bhumisiri Mangkhalanusorn Building, M Floor, Zone C, 1873 Rama IV Rd, Bangkok, Pathumwan, 10330, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Veraprapas Kittipibul
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bhumisiri Mangkhalanusorn Building, M Floor, Zone C, 1873 Rama IV Rd, Bangkok, Pathumwan, 10330, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Panudda Srichomkwun
- Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center in Diabetes, Hormones and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Smonporn Boonyaratavej
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bhumisiri Mangkhalanusorn Building, M Floor, Zone C, 1873 Rama IV Rd, Bangkok, Pathumwan, 10330, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bhumisiri Mangkhalanusorn Building, M Floor, Zone C, 1873 Rama IV Rd, Bangkok, Pathumwan, 10330, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Bridwell RE, Figlewicz MR, Birdsong S, Goss S, Belcher CN. Pediatric volvulus induced thyroid storm: A case report. Am J Emerg Med 2021; 49:439.e3-439.e5. [PMID: 33926769 DOI: 10.1016/j.ajem.2021.04.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022] Open
Abstract
Thyroid storm is an unusually rare but life-threatening pediatric occurrence, carrying significant mortality. Skewed towards the adolescent population, thyroid decompensation occurs due to inciting factors ranging from infection, trauma, surgery, burns, medications, direct thyroid trauma, and rarely volvulus. Emergent care focuses on both reversing the inciting event as well as quelling the metabolic hyperactivity associated with thyroid storm. In review of the available literature, this case is the first to date of thyroid storm secondary to malrotation with midgut volvulus in a previously euthyroid adolescent patient.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Matthew R Figlewicz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Sara Birdsong
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Sarah Goss
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Christopher N Belcher
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
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62
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Crudo DF, Walsh ET, Hunter JD. Recurrent Concurrent Diabetic Ketoacidosis and Thyroid Storm. Cureus 2021; 13:e14273. [PMID: 33959452 PMCID: PMC8093116 DOI: 10.7759/cureus.14273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Diabetic ketoacidosis (DKA) and thyroid storm are serious complications of underlying disease states. Either condition can induce the other, and the co-occurrence of these conditions is uncommon. We present the case of an adolescent patient with type 1 diabetes and autoimmune hypothyroidism who developed recurrent concurrent DKA and thyroid storm twice in an eight-month period. The simultaneous development of DKA and thyroid storm is uncommon with only 28 cases previously reported. Co-presentation of these two life-threatening conditions occurs in people with either preexisting diabetes, thyroid disease, or both. The purported pathophysiology of how DKA and thyroid storm affect the other is discussed.
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Affiliation(s)
- David F Crudo
- Pediatric Endocrinology, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Elizabeth T Walsh
- Pediatric Endocrinology, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Janel D Hunter
- Pediatric Endocrinology, Wake Forest University School of Medicine, Winston-Salem, USA
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Gómez-Isaza L, González-Ortega N, Cameselle-Teijeiro JM. Pathological thyroid findings in amiodarone-induced thyrotoxicosis. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2021; 54:123-126. [PMID: 33726888 DOI: 10.1016/j.patol.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 04/18/2019] [Indexed: 10/21/2022]
Abstract
Amiodarone (AMD) is a class III antiarrhythmic drug whose chronic or high dosage administration alters the tests of thyroid function. AMD is also associated with hypothyroidism or thyrotoxicosis. Total thyroidectomy is an efficient treatment of AMD-induced thyrotoxicosis in cases resistant to medical therapy, worsening of cardiac function and/or severe thyrotoxicosis. Although AMD is a widely used drug, its pathological consequences are not well known. We describe the pathological findings in the thyroid gland of a patient who underwent total thyroidectomy due to AMD-induced thyrotoxicosis. The surgical specimen was macroscopically normal, but histologically showed multiple follicles totally or partially invaded by clear vacuolated (foamy) histiocytes, sometimes multinucleated. Loss of thyrocytes, breaks in the follicular basal membrane and stromal fibrosis could also be appreciated but no lymphocytic infiltrates were found. An awareness of these histopathological features is particularly important for surgical pathologists, especially as there are very few published reports describing these alterations.
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Affiliation(s)
- Laura Gómez-Isaza
- Department of Anatomic Pathology and Clinical Pathology, University of Valle, Cali, Valle del Cauca, Colombia
| | - Noel González-Ortega
- Department of Anatomic Pathology, Clinical University Hospital, SERGAS, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Manuel Cameselle-Teijeiro
- Department of Anatomic Pathology, Clinical University Hospital, SERGAS, University of Santiago de Compostela, Santiago de Compostela, Spain.
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Merkle JE, Boudreaux B, Langohr I, Hegler A, Ryan K, Fletcher J. Thyroid storm in a dog secondary to thyroid carcinoma. J Vet Emerg Crit Care (San Antonio) 2021; 31:428-431. [PMID: 33792155 DOI: 10.1111/vec.13051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/29/2019] [Accepted: 07/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the clinical presentation, clinical course, and management of a dog with thyroid storm (TS) secondary to a functional thyroid carcinoma. CASE SUMMARY A 12-year-old neutered female Golden Retriever was evaluated for severe weight loss, hyperthermia, and tachycardia. The dog had a ventral neck mass and markedly increased thyroxine concentration. Cervical ultrasound showed a suspected left thyroid mass with invasion into the jugular vein. Despite aggressive therapy, the patient progressed to a clinical TS. Postmortem examination was supportive of the clinical diagnosis. NEW OR UNIQUE INFORMATION PROVIDED To the authors' knowledge, this is the first report of TS in a dog.
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Affiliation(s)
- Jennifer E Merkle
- Department of Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Bonnie Boudreaux
- Department of Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Ingeborg Langohr
- Department of Pathobiological Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Ashley Hegler
- Department of Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Kirk Ryan
- Department of Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Jon Fletcher
- Department of Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
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65
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Cruz-Flores S. Neurological Complications of Endocrine Emergencies. Curr Neurol Neurosci Rep 2021; 21:21. [PMID: 33709163 DOI: 10.1007/s11910-021-01105-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Endocrine disorders are the result of insufficient or excessive hormonal production. The clinical course is long, and the manifestations are nonspecific due to the systemic effect of hormones across many organs and systems including the nervous system. This is a narrative review of the recent evidence of the diagnosis and treatment approach of these medical and neurological emergencies. RECENT FINDINGS With the possible exception of diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia, endocrinological emergencies are complex, uncommon yet life-threatening conditions with protean and often nonspecific early clinical signs. They frequently are the first manifestation of the endocrine derangement. The systemic effects of hormones extend to the nervous system and as such, these conditions can present with neurological complications manifested, in most cases, by a diffuse dysfunction of the brain in the form of encephalopathy, delirium, seizures, and coma; or specific and peculiar syndromes such as hemichorea, hemiballism, and epilepsia partialis continua. The severity of these conditions often necessitates management in the intensive care unit requiring substantial supportive care in addition to specific targeted therapy to correct the hormonal metabolic abnormalities while at the same time blocking hormonal activity, in cases of excessive function, or supplementing hormonal deficiencies. Endocrine emergencies and their neurological complications are infrequent. The major challenge for most is early recognition. Their morbidity and mortality are high and their diagnosis requires high index of suspicion. The neurological complication most often improves with the correction of the metabolic derangement and their acuity and severity require admission to the intensive care unit.
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Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.
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66
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Fazendin JM, Smithson M, Asban A, Chen H, Lindeman B. The euthyroid state: An often difficult-to-achieve (and unnecessary?) goal at the time of surgery. Am J Surg 2021; 222:499-500. [PMID: 33726920 DOI: 10.1016/j.amjsurg.2021.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Jessica M Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Mary Smithson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar Asban
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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67
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Katherine Burton BS, Mondragon J, Ong N, Buckley C. Thyroid storm obscured by acute asthma exacerbation and concurrent H1N1 influenza. Am J Emerg Med 2021; 45:680.e5-680.e6. [PMID: 33583620 DOI: 10.1016/j.ajem.2020.11.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/27/2020] [Accepted: 11/29/2020] [Indexed: 10/22/2022] Open
Abstract
We present an uncommon case of H1N1 triggered thyroid storm in a patient with previously undiagnosed Grave's Disease. This case illustrates the challenges of diagnosing thyroid storm in the emergency department and the importance of including it in the differential when treating more common diagnoses that fail to respond to usual therapies. Thyroid storm is an endocrinologic emergency and requires prompt recognition and treatment. However, it remains a diagnostic challenge as there is no laboratory test specific to thyroid storm. Diagnosis relies on clinical suspicion in corroboration with patient presentation, laboratory findings and response to therapy.
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Affiliation(s)
- B S Katherine Burton
- Baylor Scott and White Medical Center - Temple, MS-11-AG062, 2401 S 31st St, 76508 Temple, TX, USA
| | - Jonathan Mondragon
- Baylor Scott and White Medical Center - Temple, MS-11-AG062, 2401 S 31st St, 76508 Temple, TX, USA
| | - Nicolas Ong
- Baylor Scott and White Medical Center - Temple, MS-11-AG062, 2401 S 31st St, 76508 Temple, TX, USA.
| | - Clifford Buckley
- Baylor Scott and White Medical Center - Temple, MS-11-AG062, 2401 S 31st St, 76508 Temple, TX, USA
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Albehair MA, Alagga AA, Ghulam WZ, Alomair AM, AlFaraj D. Thyroid Storm: Unusual Presentation and Complication. Cureus 2021; 13:e12483. [PMID: 33425557 PMCID: PMC7785469 DOI: 10.7759/cureus.12483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thyroid storm is a rare and a life-threatening condition, and serious complications could happen if not diagnosed and managed early. The typical clinical manifestations of hyperthyroidism are exaggerated in thyroid storm, particularly marked pyrexia and tachycardia, and altered mental status as agitation, delirium, or coma. Many precipitating factors contribute to the presentation of thyroid storm, and new recent factors like Epstein-Barr virus (EBV) could play a significant role. Serious and rare complications from the thyroid storm can increase the risk of mortality and morbidity up to 30% as fulminant hepatic failure, which is reported only a handful of times in the literature. Also, congestive heart failure can be part of the multiorgan dysfunction from the presentation, if associated with the thyroid storm. In this report, we present a case of thyroid storm precipitated by EBV and causing fast atrial fibrillation complicated by congestive heart failure and fulminant hepatic failure for 46-year-old Bangladeshi male not known to have any medical illness. He presented to the emergency department with 10-day history of an on and off subjective fever, associated with generalized abdominal pain and vomiting. He developed palpitation at the day of presentation. He was managed, stabilized, intubated, and shifted to the ICU as the patient started to be apneic after the conscious sedation for the cardioversion. During the admission anti-EBV viral capsid antigen IgM antibody was positive. The patient was discharged after five days in ICU and 14 days of overall hospital stay. Although the complication of thyroid storm as fulminant hepatic failure and congestive heart failure are rare, they should be considered in cases with thyroid storm. The pre-existing of EBV as a precipitating factor should always be considered, and more studies in these regards need to be done.
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Affiliation(s)
- Maan A Albehair
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Weaam Z Ghulam
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Dunya AlFaraj
- Emergency Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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Sanchez AP, Balogun RA. Therapeutic Plasma Exchange in the Critically Ill Patient: Technology and Indications. Adv Chronic Kidney Dis 2021; 28:59-73. [PMID: 34389138 DOI: 10.1053/j.ackd.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/20/2021] [Accepted: 03/17/2021] [Indexed: 12/17/2022]
Abstract
Therapeutic plasma exchange (TPE) is frequently the most common Apheresis Medicine technique used for extracorporeal therapy of a wide variety of renal, neurological, hematological, and other clinical indications. Many of these clinical indications require intensive care during critical illness. Conventional TPE uses one of two main technical methods to achieve the goal of removing known disease mediators from the plasma: using centrifugal forces to separate and remove components of blood, or a membrane filtration method that separates plasma from the cellular components of blood. The following review discusses the basic principles of TPE, the technological aspects, and relevant clinical scenarios encountered in the intensive care unit, including relevant guidelines and recommendations from the American Society for Apheresis.
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Lim SL, Wang K, Lui PL, Ramanathan K, Yang SP. Crash Landing of Thyroid Storm: A Case Report and Review of the Role of Extra-Corporeal Systems. Front Endocrinol (Lausanne) 2021; 12:725559. [PMID: 34489870 PMCID: PMC8417732 DOI: 10.3389/fendo.2021.725559] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/06/2021] [Indexed: 01/09/2023] Open
Abstract
Thyroid storm is a rare but life-threatening endocrinological emergency with significant mortality ranging from 10-30% with multi-organ involvement and failure. In view of the rarity of this condition and efficacy of established first line medical treatment, use of extra-corporeal treatments are uncommon, not well-studied, and its available evidence exists only from case reports and case series. We describe a 28-year-old man who presented with an out-of-hospital cardiac arrest secondary to thyroid storm. Despite conventional first-line pharmacotherapy, he developed cardiogenic shock and circulatory collapse with intravenous esmolol infusion, as well as multi-organ failure. He required therapeutic plasma exchange, concurrent renal replacement therapy, and veno-arterial extra-corporeal membrane oxygenation, one of the few reported cases in the literature. While there was clinical stabilization and improvement in tri-iodothyronine levels on three extra-corporeal systems, he suffered irreversible hypoxic-ischemic brain injury. We reviewed the use of early therapeutic plasma exchange and extra-corporeal membrane oxygenation, as well as the development of other novel extra-corporeal modalities when conventional pharmacotherapy is unsuccessful or contraindicated. This case also highlights the complexities in the management of thyroid storm, calling for caution with beta-blockade use in thyrocardiac disease, with close monitoring and prompt organ support.
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Affiliation(s)
- Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore, Singapore
- *Correspondence: Shir Lynn Lim,
| | - Kangjie Wang
- Division of Endocrinology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Pak Ling Lui
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Center, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Samantha Peiling Yang
- Division of Endocrinology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, Singapore, Singapore
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Park BD, Lyn-Kew K, Granchelli A, Mehta A. A 62-Year-Old Woman With Diffuse Myalgias, Fatigue, and Shortness of Breath. Chest 2020; 157:e75-e78. [PMID: 32145820 DOI: 10.1016/j.chest.2019.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/16/2019] [Accepted: 09/30/2019] [Indexed: 10/24/2022] Open
Abstract
CASE PRESENTATION A 62-year-old woman with a history of partially treated Graves disease and hypertension presented with approximately 3 weeks of worsening fatigue, lower extremity myalgias, and shortness of breath. Her medical history included a thyroid radiofrequency ablation several years earlier. Following the ablation, she was found to have some residual thyroid activity, negating the need for therapy. She was lost to follow-up after months of normal thyroid-stimulating hormone values. On this presentation, the patient was noted to be in atrial fibrillation with a rapid ventricular rate, and although she presented alert and oriented initially, she developed progressive inattentiveness and confusion while in the ED. The patient was transferred to the medical ICU for further management of her rapid heart rate and progressive delirium.
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Affiliation(s)
- Bryan D Park
- Department of Internal Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO.
| | - Kenneth Lyn-Kew
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Ann Granchelli
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Anuj Mehta
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
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Apathetic Thyroid Storm with Cardiorespiratory Failure, Pulmonary Embolism, and Coagulopathy in a Young Male with Graves' Disease and Myopathy. Case Rep Endocrinol 2020; 2020:8896777. [PMID: 33029436 PMCID: PMC7530497 DOI: 10.1155/2020/8896777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/21/2020] [Accepted: 09/11/2020] [Indexed: 11/17/2022] Open
Abstract
A 38-year-old gentleman presented with thyroid storm with multiorgan involvement in the form of heart failure (thyrotoxic cardiomyopathy), respiratory failure (respiratory muscle fatigue), hepatic dysfunction, fast atrial fibrillation, pulmonary embolism, and disseminated intravascular coagulation (DIC). His Graves' disease (GD) remained undiagnosed for nearly 8 months because apart from weight loss, he has not had any other symptoms of thyrotoxicosis. The presentation of thyroid storm was atypical (apathetic thyroid storm) with features of depression and extreme lethargy without any fever, anxiety, agitation, or seizure. There were no identifiable triggers for the thyroid storm. Apart from mechanical ventilation and continuous veno-venous renal replacement therapy in the intensive care unit, he received propylthiouracil (PTU), esmolol, and corticosteroids, which were later switched to carbimazole and propranolol with steroids being tapered down. He was diagnosed with thyrotoxic myopathy which, like GD, remained undiagnosed for long (fatigability). A high index of suspicion and a multidisciplinary care are essential for good outcome in these patients.
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73
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Stelmachowska-Banaś M, Czajka-Oraniec I. Management of endocrine immune-related adverse events of immune checkpoint inhibitors: an updated review. Endocr Connect 2020; 9:R207-R228. [PMID: 33064663 PMCID: PMC7576644 DOI: 10.1530/ec-20-0342] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
Immune checkpoint inhibitors (ICIs) belong to a new group of anticancer drugs targeting T-cell proteins involved in the activation of immune response toward malignancies. Their introduction into clinical practice was a milestone in modern cancer treatment. However, the significant advantage of ICIs over conventional chemotherapy in terms of therapeutic efficacy is accompanied by new challenges related to specific side effects. ICI-induced immune system activation could lead to the loss of self-tolerance, presenting as autoimmune inflammation and dysfunction of various tissues and organs. Thus, the typical side effects of ICIs include immune-related adverse events (irAEs), among which endocrine irAEs, affecting numerous endocrine glands, have been commonly recognized. This review aimed to outline the current knowledge regarding ICI-induced endocrine disorders from a clinical perspective. We present updated information on the incidence and clinical development of ICI-induced endocrinopathies, including the most frequent thyroiditis and hypophysitis, the rarely observed insulin-dependent diabetes mellitus and primary adrenal insufficiency, and the recently described cases of hypoparathyroidism and lipodystrophy. Practical guidelines for monitoring, diagnosis, and treatment of ICI-related endocrine toxicities are also offered. Rising awareness of endocrine irAEs among oncologists, endocrinologists, and other health professionals caring for patients receiving ICIs could contribute to better safety and efficacy. As immunotherapy becomes widespread and approved for new types of malignancies, increased incidences of endocrine irAEs are expected in the future.
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Affiliation(s)
- Maria Stelmachowska-Banaś
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
- Correspondence should be addressed to M Stelmachowska-Banaś:
| | - Izabella Czajka-Oraniec
- Department of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Polska, Poland
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Ritter K, Wolfe C. Thyroid Storm. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2020; 5:O1-O30. [PMID: 37465337 PMCID: PMC10334447 DOI: 10.21980/j8rw71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/21/2019] [Indexed: 07/20/2023]
Abstract
Audience This is a practice oral boards case which may be given to emergency medicine (EM) residents at all levels of training and recent EM graduates. Introduction/Background Thyroid storm is an acute, life-threatening endocrine emergency. It occurs when there is excess circulating thyroid hormone in the bloodstream. It may be precipitated by infection, surgery, pregnancy, trauma, thyroid medication changes, or iodinated contrast exposure. This condition must be quickly identified and treated by EM physicians in order to prevent morbidity and mortality. IThe mortality rate is between 10 and 30%1 Understanding and treating thyroid storm is included in the 2019 Model of Clinical Practice of Emergency Medicine.2. Educational Objectives At the end of this practice oral boards case, the learner will: 1) assess a patient with altered mental status in an oral boards format; 2) review appropriate laboratory testing and diagnostic imaging; 3) identify signs and symptoms of thyroid storm and 4) review appropriate pharmacologic therapies with the proper sequence and timing. Educational Methods Practice boards case. Research Methods This oral boards practice case was developed and then tested in several small group settings. First, EM resident learners discussed the case in a small group format. Their feedback was utilized to refine the case's textual information. Subsequently, EM physicians preparing for the ABEM oral board examination provided additional general feedback of the case and completed an anonymous survey regarding case quality and educational value. Results Minor changes were made based on feedback from small group sessions. The finalized case was tested with individuals, and surveys showed that 92% (12/13) of individuals rated the case quality as excellent (standard Likert scale 1-5 with 5 being Excellent). All participants responded affirmatively that the case enhanced their understanding of thyroid storm. Discussion This oral boards practice case was effective in preparing learners for the ABEM oral boards exam. Based on learner feedback, several laboratory results were added to the stimulus package and wording was edited to improve the clarity of the case. Topics Hyperthyroidism, thyrotoxicosis, thyroid storm, endocrine emergencies, altered mental status.
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Affiliation(s)
- Kathryn Ritter
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN
| | - Carmen Wolfe
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN
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Leviter JI, Sojar S, Ayala NK, Wing R. Thyrotoxicosis in a Postpartum Adolescent: A Simulation Case for Emergency Medicine Providers. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10967. [PMID: 32934982 PMCID: PMC7485909 DOI: 10.15766/mep_2374-8265.10967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/29/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Thyroid storm is a rare but life-threatening disease process that may be difficult to recognize and mimics other disease processes. It is critical for the emergency medicine clinician to be able to recognize thyroid storm in patients in order to effectively stabilize and treat them. METHODS In this standardized patient case, learners were faced with a 17-year-old postpartum woman presenting to the emergency department with respiratory distress and altered mental status secondary to thyroid storm. The target learners were emergency department providers, including residents, medical students, and advanced practice practitioners. Providers were expected to identify signs and symptoms of thyroid storm and to initiate appropriate diagnostic workup and management of this complex patient. Debriefing followed the simulation using a debriefing guide and PowerPoint presentation. RESULTS Thirty-four learners participated in this simulation. All learners agreed or strongly agreed that the simulation case was relevant to their work, and 97% agreed or strongly agreed that it was effective in teaching thyroid storm management skills. Eighty-five percent felt that following the simulation, they would be confident in their ability to recognize thyroid storm in a postpartum patient and to recognize and manage respiratory distress and altered mental status in a postpartum patient. DISCUSSION Learners felt that this case was effective in teaching the skills necessary for caring for postpartum patients with respiratory distress and altered mental status. Future directions include conducting the simulation in situ to include multidisciplinary teams and increasing the learner pool to include OB/GYN residents.
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Affiliation(s)
- Julie I. Leviter
- Assistant Professor of Clinical Pediatrics, Department of Pediatric Emergency Medicine, Yale University School of Medicine
| | - Sakina Sojar
- Pediatric Emergency Medicine Fellow, Departments of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University and Hasbro Children's Hospital/Rhode Island Hospital
| | - Nina K. Ayala
- Maternal Fetal Medicine Fellow, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University and Women & Infants Hospital of Rhode Island
| | - Robyn Wing
- Assistant Professor, Departments of Emergency Medicine and Pediatrics, Division of Pediatric Emergency Medicine, Warren Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital; Director of Pediatric Simulation, Lifespan Medical Simulation Center
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76
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Potter JJ, Cook J, Meakin LB. Suspected thyroid storm in a cat anaesthetised for bilateral thyroidectomy. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2019-000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Joanna Jane Potter
- Veterinary AnaesthesiaUniversity College Dublin School of Agriculture Food Science and Veterinary MedicineDublinIreland
| | | | - Lee B Meakin
- Small Animal SurgeryUniversity of Bristol Faculty of Medical and Veterinary SciencesBristolUK
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Sekandarzad A, Udi J, Waller CF, Bode C, Biever P. Extracorporeal Membrane Oxygenation Support as a Bridge to Recovery during Chemotherapy in a Young Patient with Metastatic Choriocarcinoma and Severe Acute Respiratory Distress Syndrome. Oncol Res Treat 2020; 43:559-564. [PMID: 32810849 DOI: 10.1159/000509428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/14/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A young woman presented at a local hospital with severe dyspnea directly after childbirth. She was di-agnosed with choriocarcinoma and massive pulmonary metastases. Shortly after administration of polychemotherapy she developed severe acute respiratory distress syndrome (ARDS). CASE PRESENTATION The patient was transferred to the intensive care unit (ICU) and extracorporeal membrane oxygenation (ECMO) center of the university hospital. Venovenous ECMO support was implemented for 28 days while enabling continuous chemotherapy. After 49 days in the ICU, she was transferred to the oncology ward in a stable respiratory state. DISCUSSION/CONCLUSION Although the survival rates of ARDS in the general ICU population have improved lately due to improved management of ARDS and ECMO support, the data on adult cancer patients receiving ECMO support are very limited. Only few small retrospective studies on ECMO support in adult cancer patients have been conducted. Unfortunately the survival rates of patients after allogenic hematopoietic stem cell transplantation and ECMO support were discouraging. Nevertheless, cancer patients with at least stable disease who are eligible for full-code ICU management may be potential candidates for ECMO in case of severe ARDS. Our case report not only shows that patients suffering from choriocarcinoma with pulmonary metastases may develop severe ARDS in the context of polychemotherapy, but also demonstrates that ECMO support enables chemotherapy continuation and complete remission of the underlying choriocarcinoma.
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Affiliation(s)
- Asieb Sekandarzad
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, .,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Josefina Udi
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Cornelius F Waller
- Department of Haematology, Oncology and Stem Cell Transplantation, Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Gaballa S, Hlaing KM, Bos N, Moursy S, Hakami M. A Rare Case of Subacute Painful Thyroiditis Causing Thyroid Storm and a Successful Trial of Propylthiouracil. Cureus 2020; 12:e9461. [PMID: 32760639 PMCID: PMC7392358 DOI: 10.7759/cureus.9461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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79
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Senda A, Endo A, Tachimori H, Fushimi K, Otomo Y. Early administration of glucocorticoid for thyroid storm: analysis of a national administrative database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:470. [PMID: 32727523 PMCID: PMC7391822 DOI: 10.1186/s13054-020-03188-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/20/2020] [Indexed: 12/29/2022]
Abstract
Background Thyroid storm is a life-threatening disease with a mortality rate of over 10%. Although glucocorticoids have been recommended as a treatment option for thyroid storm, supportive evidence based on a large-scale clinical research is lacking. The objective of the current study was to evaluate the beneficial effects of glucocorticoids in the treatment of patients with severe thyroid storm. Methods A retrospective nationwide cohort study was conducted using a Japanese national administrative claims database. Patients admitted to intensive care units due to severe thyroid storm between the financial years 2013 and 2017 were included in the study. The primary outcome was in-hospital mortality; secondary outcomes were mortality within 30 days and insulin administration during hospitalization. Generalized linear mixed model (GLMM) with maximum likelihood estimation (MLE) and Bayesian estimation using Markov chain Monte Carlo methods (MCMC), in addition to propensity score matching (PSM), were used for statistical analysis. Results A total of 811 patients were included in the study, of which 600 patients were treated with glucocorticoids, and 211 patients were treated without glucocorticoids. The early administration of glucocorticoids was not associated with a significant improvement in the in-hospital mortality of patients with thyroid storm [adjusted odds ratio (95% confidence interval) = 1.77 (0.95–3.34), 1.44 (1.14–1.93), and 1.46 (0.72–3.00) in the GLMM (MLE), GLMM (MCMC), and PSM, respectively]. The results of mortality within 30 days were almost identical to the results of in-hospital mortality. However, insulin use was significantly higher in the glucocorticoid group. Conclusions This analysis of a nationwide administrative database indicates that the administration of glucocorticoids does not improve the survival of patients with thyroid storm.
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Affiliation(s)
- Atsushi Senda
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Akira Endo
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Hisateru Tachimori
- Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi, Kodaira, Tokyo, 187-0031, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Yasuhiro Otomo
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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80
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Hsieh LB, Yen TWF, Dream S, Patel D, Evans DB, Wang TS. Perioperative Management and Outcomes of Hyperthyroid Patients Unable to Tolerate Antithyroid Drugs. World J Surg 2020; 44:3770-3777. [PMID: 32572525 DOI: 10.1007/s00268-020-05654-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prior to thyroidectomy for hyperthyroidism, it is recommended that patients are managed with antithyroid drugs (ATDs) and rendered euthyroid to decrease the risk of thyroid storm. However, not all patients tolerate ATD and the risk of thyroid storm during thyroidectomy in these patients is unclear. Therefore, the aim of this study was to compare the management and outcomes of hyperthyroid patients that were on ATDs prior to surgery to those who were not. STUDY DESIGN A prospectively maintained, single-institution database was queried for all hyperthyroid patients who were initially treated with ATDs and underwent thyroidectomy from January 1, 2012, to June 18, 2018. Patients were divided into two groups: (1) those on ATDs at surgery (ATD group) and (2) those who could not tolerate and stopped ATDs prior to surgery (no-ATD group). Demographic and clinical data were collected. Primary outcomes were readmissions/emergency department visits and postoperative complications within 30 days of thyroidectomy. RESULTS Of the 248 patients, 231 were in the ATD group and 17 (7%) were in the no-ATD group. There were no mortalities or thyroid storm events in either group. There was no difference in Clavien-Dindo Grade 2 or 3 complications between the two groups. There were no ED visits or 30-day readmissions in the no-ATD group compared to 17 (7%) events in the ATD group (p = 1.0). CONCLUSION While it is preferable to render patients euthyroid prior to thyroidectomy for hyperthyroidism, results of this study suggest that when patients cannot tolerate ATDs, it is possible to perform thyroidectomy without increased risk of thyroid storm or intra- and postoperative complications.
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Affiliation(s)
- Lily B Hsieh
- Section of Endocrine Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA
| | - Tina W F Yen
- Section of Endocrine Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA
| | - Sophie Dream
- Section of Endocrine Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA
| | - Dhaval Patel
- Section of Endocrine Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA
| | - Douglas B Evans
- Section of Endocrine Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA
| | - Tracy S Wang
- Section of Endocrine Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA.
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81
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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82
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Abstract
Mortality in thyroid storm, without appropriate treatment, can rise as high as 100%. Thyroid storm coexisting with ischemic stroke is a rare presentation that further increases the risk of mortality. Early recognition and appropriate management are critical to the prevention of mortality and morbidity. Here, we review the case of a 63-year-old male presenting with new neurological deficits who was found to have thyroid storm; appropriate management of the co-existing conditions are also reviewed.
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Affiliation(s)
- Samantha Snyder
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Maria Joseph
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
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83
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Peace JM, Hire MG, Peralta FM. Postpartum Thyroid Storm in Poorly Controlled Graves' Disease: A Case Report. A A Pract 2020; 13:299-302. [PMID: 31274513 DOI: 10.1213/xaa.0000000000001059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hyperthyroidism during pregnancy is a relatively rare event, but poor control of hyperthyroidism during pregnancy is associated with a host of issues. These include intrauterine fetal demise, hypertensive disorders of pregnancy, preterm delivery, low birth weight, intrauterine growth restriction, and maternal congestive heart failure. One of the most feared sequelae of hyperthyroidism is thyroid storm, which has a mortality rate >10%. Patients who develop thyroid storm present several challenges to anesthesiologists including hemodynamic instability and medication management. Here, we present the anesthetic management for a parturient whose delivery was complicated by signs and symptoms consistent with thyroid storm.
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Affiliation(s)
- Jack M Peace
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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84
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Ladd JM, Sabsabi B, von Oettingen JE. Thyroid Storm in a Toddler Presenting as a Febrile Seizure. Pediatrics 2020; 145:peds.2019-1920. [PMID: 31980544 DOI: 10.1542/peds.2019-1920] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 11/24/2022] Open
Abstract
Although simple febrile seizures are relatively common and benign in toddlers, it is important to rule out any underlying critical disease that necessitates further intervention and treatment. Thyroid storm, the extreme manifestation of hyperthyroidism, is relatively rare and not often considered in the differential diagnosis of a febrile seizure despite its high mortality rate. Here, we report 1 of the youngest patients with thyroid storm, who initially presented with a febrile seizure. After reevaluation, the 2-year-9-month-old patient was discovered to have thyromegaly, which led to recognition that her persistent tachycardia and widened pulse pressure were likely signs of thyrotoxicosis. Laboratory results were consistent with primary hyperthyroidism due to Graves' disease. Thyroid storm was then diagnosed on the basis of clinical features including gastrointestinal and central nervous system disturbances. Treatment with methimazole, propranolol, hydrocortisone, and Lugol's iodine solution was used. This medication regimen was safe and effective with restoration of a euthyroid state after 2 months and no recurrence of seizures. Improved awareness of hyperthyroidism and thyroid storm can lead to prompt diagnosis and treatment of this endocrine emergency, thus reducing mortality and morbidity. Pediatricians should consider this diagnosis in children with febrile seizures and suggestive vital signs and physical examination findings.
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Affiliation(s)
- Jennifer M Ladd
- Division of Pediatric Endocrinology, Department of Pediatrics and
| | - Bayane Sabsabi
- Division of General Pediatrics, Department of Pediatrics, McGill University, Montreal, Canada; and
| | - Julia E von Oettingen
- Division of Pediatric Endocrinology, Department of Pediatrics and.,The Research Institute of the McGill University Health Centre, Montreal, Canada
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85
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Pinto A, Drake T, Cayci Z, Burmeister LA. THYROID STORM WITH COMA IN A PATIENT WITH METASTATIC THYROID CARCINOMA AND GRAVES DISEASE: WON THE BATTLE BUT LOST THE WAR. AACE Clin Case Rep 2020; 5:e7-e12. [PMID: 31966991 DOI: 10.4158/accr-2018-0262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/13/2018] [Indexed: 11/15/2022] Open
Abstract
Objective To describe the background and events that may precipitate thyroid storm (TS) with coma as well as the course of treatment intervention and our patient's response to treatment. Methods We present a case of TS with coma including precipitants, thyroid function tests, thyroid ultrasound, computed tomography findings, course, treatment, and outcome. Results A 71-year-old woman was hospitalized with back pain and right leg weakness due to a newly diagnosed, 12.4-cm sacral tumor. The tumor had metastasized from poorly differentiated papillary thyroid carcinoma. The patient developed TS characterized by thyrotoxicosis with fever, tachycardia, and mental status change progressing to coma over several days. Treatment including antithyroid drugs, steroids, saturated solution of potassium iodide, L-carnitine, therapeutic plasma exchange, and thyroidectomy reversed the prolonged coma and TS, but left residual flaccid quadriplegia. The patient eventually died. Conclusion This patient presented with multiple rare causes of TS (computed tomography contrast and Graves disease in the setting of high-volume thyroid cancer) and a rare manifestation of TS (coma). The TS included fever, tachycardia, and rapid onset of prolonged coma in the setting of thyrotoxicosis. Precipitants of the TS may have included enlarged thyroid tissue from goiter, distant metastasis, the operation, computed tomography contrast exposure, and high levels of thyroid-stimulating immunoglobulin. Multifaceted treatments, most importantly therapeutic plasma exchange, resolved the coma and TS, but the patient still succumbed to comorbidity. We agree with the Japan Thyroid Association recommendation for therapeutic plasma exchange in patients with TS, especially those in a coma who do not awaken within 24 to 48 hours of starting conventional TS treatment.
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86
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 787] [Impact Index Per Article: 157.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Abstract
Fever is a common clinical sign encountered in hospitalized patients and often represents the cardinal sign of infectious processes. However, a number of noninfectious etiologies causing fever should be considered prior to initiating broad-spectrum antibiotic therapy. Reducing unnecessary antibiotic use is crucial in an era of increasing resistance.
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88
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Takahashi M, Kondo T, Yamasaki G, Sugimoto M, Kuse A, Morichika M, Nakagawa K, Ueno Y. An autopsy case of thyroid storm associated with chronic lymphocytic thyroiditis. Leg Med (Tokyo) 2019; 44:101624. [PMID: 32259690 DOI: 10.1016/j.legalmed.2019.101624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/15/2019] [Accepted: 09/03/2019] [Indexed: 11/17/2022]
Abstract
A Japanese woman in her 30s was found dead on a mattress. She had had fever, cough, and dyspnea for about 2 weeks. Gross examination at autopsy revealed slight enlargement of the thyroid gland and histopathological examination resulted in a diagnosis of chronic lymphocytic thyroiditis. The concentration of triiodothyronine in the cadaveric blood was extraordinarily high, whereas that of thyroid stimulating hormone was below the detection limit. Autoimmune antibodies against thyroid tissue were positive. The cause of death was assumed to be congestive heart failure caused by thyroid storm associated with chronic lymphocytic thyroiditis. Systemic histopathological examination of tissues and postmortem biochemistry can enable a diagnosis in medicolegal autopsies.
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Affiliation(s)
- Motonori Takahashi
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan.
| | - Takeshi Kondo
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Gentaro Yamasaki
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Marie Sugimoto
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Azumi Kuse
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Mai Morichika
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Kanako Nakagawa
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Yasuhiro Ueno
- Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
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89
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Trohman RG, Sharma PS, McAninch EA, Bianco AC. Amiodarone and thyroid physiology, pathophysiology, diagnosis and management. Trends Cardiovasc Med 2019; 29:285-295. [PMID: 30309693 PMCID: PMC6661016 DOI: 10.1016/j.tcm.2018.09.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 08/15/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
Although amiodarone is considered the most effective antiarrhythmic agent, its use is limited by a wide variety of potential toxicities. The purpose of this review is to provide a comprehensive "bench to bedside" overview of the ways amiodarone influences thyroid function. We performed a systematic search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2017. Amiodarone was searched using the terms adverse effects, hypothyroidism, myxedema, hyperthyroidism, thyroid storm, atrial fibrillation, ventricular arrhythmia, and electrical storm. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. We included 163 germane references in this review. Because amiodarone is one of the most frequently prescribed antiarrhythmic drugs in the United States, the mechanistic, diagnostic and therapeutic information provided is relevant for practicing clinicians in a wide range of medical specialties.
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Affiliation(s)
- Richard G Trohman
- Divisions of Cardiology and Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States.
| | - Parikshit S Sharma
- Divisions of Cardiology and Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Elizabeth A McAninch
- Divisions of Cardiology and Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Antonio C Bianco
- Divisions of Cardiology and Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
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90
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Rathish D, Karalliyadda S. Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases. BMC Endocr Disord 2019; 19:49. [PMID: 31101104 PMCID: PMC6525384 DOI: 10.1186/s12902-019-0374-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/23/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Simultaneous development of thyroid storm and diabetic ketoacidosis (DKA) is a rare condition. The review aims to summarise its clinical presentation, investigation findings and treatment options. METHODS Databases and reference lists of the selected articles were searched for case reports in English which describe concurrent presentation of thyroid storm and diabetic ketoacidosis. CARE guidelines were used for the quality assessment of the selected articles. RESULTS Twenty-six cases from twenty-one articles were selected out of 198 search results. Western Pacific, and American regions contributed to 77% of the cases. Females were most affected (88%). Features of Graves' disease like hyperthermia and tachycardia, gastrointestinal and neuro-psychiatric disturbances were the common clinical presentations. In most of the cases, previous diagnosis of diabetes mellitus preceded that of Graves' disease (46%). Among patients having their drug compliance reported, all had poor compliance to their routine anti-thyroid (9/9) and anti-diabetic (2/2) agents. Moreover, in all cases where HbA1C (7/7) and T4 (16/16) were measured, the results were elevated and where TSH (17/17) was measured, the results were low. The recommended treatment for DKA and thyroid storm was used in most cases and methimazole was the thionamide of choice in the latest four cases reported. All cases survived except four (15%). CONCLUSIONS Concurrent presentation of thyroid storm and diabetic ketoacidosis is rare but life-threatening. Therefore, efforts should be made to maximise patient compliance to anti-thyroid and anti-diabetic agents in treating such patients.
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Affiliation(s)
- Devarajan Rathish
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008 Sri Lanka
| | - Senuri Karalliyadda
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, 50008 Sri Lanka
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91
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Thyrotoxicosis: an unusual cause of syncope. Am J Emerg Med 2019; 37:797.e5-797.e6. [DOI: 10.1016/j.ajem.2019.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/12/2019] [Indexed: 11/22/2022] Open
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92
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Chen AW, Wee HC, Sonawane V. FLAIL MITRAL VALVE: A RARE COMPLICATION OF A THYROID STORM. AACE Clin Case Rep 2019; 5:e4-e6. [PMID: 31966990 DOI: 10.4158/accr-2018-0137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/08/2018] [Indexed: 11/15/2022] Open
Abstract
Objective Thyroid storm is a life-threatening presentation, with heart failure and tachyarrhythmias being common manifestations. This case highlights that a flail mitral valve from chordae tendineae rupture can be a cause of worsening heart failure and cardiogenic shock in a thyroid storm, albeit a rare complication. Methods We describe a patient who was admitted for a thyroid storm precipitated by pneumonia, who later developed an acute flail mitral valve from chordae tendineae rupture. Results A 55-year-old woman with no past medical history was admitted with fever, dyspnea, lower limb swelling, and hemoptysis. She was febrile, tachycardic, and in fluid overload. Her heart sounds were dual, and no murmurs were heard. Initial investigations indicated primary hyperthyroidism and pneumonia. She was diagnosed with a thyroid storm precipitated by pneumonia, complicated by heart failure. Her Burch-Wartofsky score was 70. She was started on intravenous hydrocortisone, oral propylthiouracil, oral Lugol's iodine, and oral cholestyramine, together with intravenous amoxicillin-clavulanate and intravenous furosemide. She continued to deteriorate in the medical intensive care unit, with worsening hypoxia and hypotension. Echocardiography showed an acute flail posterior mitral valve leaflet with torrential mitral regurgitation from rupture of the chordae tendineae. She subsequently underwent a bioprosthetic mitral valve replacement. Conclusion An acute flail mitral valve precipitated by thyroid storm leading to refractory cardiogenic shock is rare. Factors contributing to the rupture of valve chordae tendineae include the effect of hyperthyroidism on papillary muscle function, a hyperdynamic circulation leading to vulvular stress, as well as pre-existing mitral valve pathology.
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93
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Stumpf MAM, Schrut GCA, Ramthun M, Onuma S, Osternack HECG. METHIMAZOLE-INDUCED AGRANULOCYTOSIS AND SEPSIS: WAS THYROID STORM PRESENT OR JUST BEING MIMICKED? ACTA ENDOCRINOLOGICA-BUCHAREST 2019; 15:522-525. [PMID: 32377252 DOI: 10.4183/aeb.2019.522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction Agranulocytosis induced by thioamides is rare, occurring only in 0.2-0.5% of cases. Case presentation We present the case of a 45-year-old woman previously diagnosed with Graves' disease that discontinued the use of methimazole on her own. She attended the Emergency Department presenting fever (40.5¯C), agitation and diaphoresis. A thyroid storm diagnosis was initially thought, but after laboratory results showing neutrophil count near 0.06x109/L, sepsis due to neutropenia seemed the most logical hypothesis. Cephepime was promptly initiated. For thyrotoxicosis management, cholestyramine and atenolol were prescribed. In her second day of hospitalization, subcutaneous granulocyte colony-stimulating factor was started for an earlier medullar response. The patient was discharged after 7 days with atenolol 50mg/day and instructed to have a definite treatment for Graves disease as soon as possible. Conclusion Such case purpose is to remember clinicians that sepsis diagnosis can be challenged, especially when a thyroid storm is a possible diagnosis as well. In this particular case, both conditions should be treated, but life-threatening sepsis should have the focus for a quick therapeutic approach.
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Affiliation(s)
- M A M Stumpf
- Ponta Grossa State University - Medicine, Ponta Grossa, Brazil
| | - G C A Schrut
- Ponta Grossa State University - Medicine, Ponta Grossa, Brazil
| | - M Ramthun
- Ponta Grossa State University - Medicine, Ponta Grossa, Brazil
| | - S Onuma
- Ponta Grossa State University - Medicine, Ponta Grossa, Brazil
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94
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Wallington D, Schauer M, Bauler LD. Simultaneous presentation of thyroid storm and diabetic ketoacidosis in a previously healthy 21-year-old man. BMJ Case Rep 2019; 12:12/1/bcr-2018-227554. [DOI: 10.1136/bcr-2018-227554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 21-year-old young man with no history of diabetes or thyroid disease presented to the emergency department with simultaneous thyroid storm and diabetic ketoacidosis. Notable findings on admission were a ventricular rate of 235 beats/min, tachypnoea, tremors, polydipsia and a lack of fever. Due to the unusual constellation of symptoms, diagnosis was only possible after initial laboratory results came back. While the lack of fever is unusual in thyroid storm, diabetic ketoacidosis has previously been reported to suppress fever, and this case supports the occurrence of this phenomenon. This case was highly unusual because the patient had not previously been diagnosed with either type 1 diabetes or Graves’ disease.
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95
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Yu HW, Bae IE, Kim SJ, Chai YJ, Moon JH, Ryu JH, Oh AY, Choi JY, Lee KE. Comparison of Intra-Operative Vital Sign Changes during Total Thyroidectomy in Patients with Controlled and Uncontrolled Graves' Disease. J Clin Med 2018; 7:jcm7120566. [PMID: 30572604 PMCID: PMC6306939 DOI: 10.3390/jcm7120566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022] Open
Abstract
Thyroid storm (TS) is a life-threatening emergency endocrine condition. Thyroid hormones should be normalized before thyroidectomy is performed in patients with Graves’ disease. However, thyroid hormone levels are inevitably high in patients undergoing surgery. This study analyzed differences in vital sign changes during thyroidectomy between patients with controlled and uncontrolled Graves’ disease and assessed thyroid hormone cutoffs for TS. Preoperative levels of the thyroid hormones free T4 (FT4), T3, and thyroid stimulating hormone (TSH) were retrospectively analyzed in patients who underwent total thyroidectomy for Graves’ disease. Patients were divided into those with uncontrolled Graves’ (UG) disease, defined as preoperative TSH <0.3 µIU/mL and FT4 >1.7 ng/dL, those with controlled Graves’ (CG) disease, those with extremely uncontrolled Graves’ (EUG) disease, defined as TSH <0.3 µIU/mL and FT4 >3.4 ng/dL, and finally, those without EUG (non-EUG). The 29 patients with Graves’ disease included 12 with CG group and 17 with UG. FT4 and T3 concentrations were significantly higher in the UG group. There were no differences in vital sign and anesthetic agent. These 29 patients could also be divided into those with (n = 4) and without EUG (n = 25). The mean age was lower (21.5 vs. 40.9 years, p < 0.001) and the mean operation time was shorter (121.4 vs. 208.8 min, p = 0.003) in the EUG group. Requirements for anesthetic agents were greater in the EUG group. Mean FT4 concentration in the EUG group was 3.8 ng/dL, and there were no changes in vital signs during surgery. Vital sign change during thyroid surgery was not observed in patients with uncontrolled Graves’ disease up to the twice upper normal limit of T4 level.
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Affiliation(s)
- Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea.
| | - In Eui Bae
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea.
| | - Su-Jin Kim
- Department of Surgery, Seoul National University Hospital and College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
| | - Young Jun Chai
- Department of Surgery, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea.
| | - Jae Hoon Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea.
| | - Jung-Hee Ryu
- Department of Anesthesiology & Pain Medicine, Seoul National University Hospital and College of Medicine and Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea.
| | - Ah-Young Oh
- Department of Anesthesiology & Pain Medicine, Seoul National University Hospital and College of Medicine and Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea.
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea.
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University Hospital and College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
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96
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Shah SR, Millan T, Alamzaib SM, Luu SW. Idiopathic thyroid storm mimicking SIRS in a patient with hypothyroidism- a diagnostic dilemma. J Community Hosp Intern Med Perspect 2018; 8:368-369. [PMID: 30559947 PMCID: PMC6292359 DOI: 10.1080/20009666.2018.1547090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022] Open
Abstract
Thyroid storm, defined as an endocrine emergency in 1926, remains a challenge for physicians in the 21st century. The mortality rate of untreated thyroid storm is very high. Hence, if a thyroid storm is suspected, treatment should not be delayed. This disease can be fatal! We present the case of a 86-year-old female presenting with altered mental status. All the tests came out negative except for elevated free t4 (ft4) with a very low TSH level (ft4-7.87, TSH< 0.005). Patient was diagnosed with thyroid storm in the setting of subclinical hypothyroidism and improved significantly with treatment. Furthermore, it is essential to confirm the TSH level in a patient with subclinical hypothyroidism. By carefully finding the extent of the disease, one can easily distinguish between hypo-or hyper- thyroid disease. The clinical features of thyroid storm may be related to other co-morbidities which makes diagnosis a clinical challenge. Nonetheless, it is important to be aware of the possibility of development of a thyroid storm in patients with a history of subclinical hypothyroidism. In addition, patients, if diagnosed with a thyroid storm, should be treated immediately with appropriate medications since thyrotoxicosis is life threatening.
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Affiliation(s)
- Syed Raza Shah
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Terance Millan
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Sardar Muhammad Alamzaib
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Sue-Wei Luu
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
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97
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Andrade Luz I, Pereira T, Catorze N. Thyroid storm: a case of haemodynamic failure promptly reversed by aggressive medical therapy with antithyroid agents and steroid pulse. BMJ Case Rep 2018; 11:11/1/e226669. [PMID: 30567262 DOI: 10.1136/bcr-2018-226669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hyperthyroidism is a common metabolic disorder, although its presentation as an endocrine emergency called thyroid storm is rare. Here we review a case of a thyroid storm as the initial presentation of thyrotoxicosis, with multiple organ failure and haemodynamic collapse due to low-output cardiac dysfunction. Quick intervention with aggressive antithyroid therapy, including steroid pulse, and supportive intensive care measures led to an outstanding improvement and full recovery. The present case clearly shows the beneficial impact of initial clinical suspicion resulting in an early diagnosis and intensive therapy. Moreover, it supports the additional role of steroids to aggressive antithyroid strategy in order to control associated deleterious systemic inflammatory reactions.
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Affiliation(s)
- Ivan Andrade Luz
- Nephrology, Centro Hospitalar do Médio Tejo EPE, Unidade de Torres Novas, Torres Novas, Santarém, Portugal
| | - Tiago Pereira
- Intensive Care Unit, Centro Hospitalar do Médio Tejo EPE, Unidade de Abrantes, Abrantes, Santarém, Portugal
| | - Nuno Catorze
- Intensive Care Unit, Centro Hospitalar do Médio Tejo EPE, Unidade de Abrantes, Abrantes, Santarém, Portugal
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98
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Boushra MN, Miller SN, Koyfman A, Long B. Consideration of Occult Infection and Sepsis Mimics in the Sick Patient Without an Apparent Infectious Source. J Emerg Med 2018; 56:36-45. [PMID: 30396751 DOI: 10.1016/j.jemermed.2018.09.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/01/2018] [Accepted: 09/20/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evaluation and treatment of the acutely ill patient is typically complicated by multiple comorbidities and incomplete medical histories. This is exemplified by patients with sepsis, whose care is complicated by variable presentations, shifting definitions, and a variety of potential sources. Many practitioners fail to consider and recognize less-common sources of infection in a timely manner. Additionally, multiple noninfectious conditions can present with the fever and tachycardia typical of the septic patient. The errors of anchoring and premature closure may lead to delay in, or failure of, diagnosis of these conditions. OBJECTIVE This review addresses the evaluation of the acutely ill-appearing patient without an apparent source, focusing on occult sources of infection and conditions that mimic sepsis. DISCUSSION Musculoskeletal, cardiac, neuraxial, and abdominal sources of sepsis should be considered in the acutely ill patient. Indwelling devices should be carefully examined for signs of infection. Consideration for sepsis mimics, such as neuroleptic malignant syndrome, malignant hyperthermia, medication toxicity, and thyroid storm, in patients who fail to respond to standard therapies for sepsis, may lead the physician to potentially reversible life-threatening diagnoses and management. CONCLUSION In the seemingly septic patient who does not respond to antimicrobials and fluids, the differential should be broadened to include acutely life-threatening conditions that can mimic sepsis. A review of the patient's medical history, medications, and recent exposures can assist in identifying the source of the patient's elevated body temperature and tachycardia. Consideration of potential sources and other mimics of sepsis is needed in the emergency department.
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Affiliation(s)
- Marina N Boushra
- Department of Emergency Medicine, Vidant Medical Center, Greenville, North Carolina
| | - Susan N Miller
- Department of Emergency Medicine, Vidant Medical Center, Greenville, North Carolina
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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99
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Wyble AJ, Moore SC, Yates SG. Weathering the storm: A case of thyroid storm refractory to conventional treatment benefiting from therapeutic plasma exchange. J Clin Apher 2018; 33:678-681. [PMID: 30321468 DOI: 10.1002/jca.21658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/05/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022]
Abstract
Thyroid storm is a severe manifestation of thyrotoxicosis characterized by systemic organ dysfunction secondary to a hypermetabolic state. Although antithyroid drugs, steroids, beta-blockers, antipyretics, and cholestyramine are the standard of care, some patients inadequately respond to these conventional therapies. Therapeutic plasma exchange has been previously utilized as a treatment modality in patients with a poor response to routine therapies or with contraindications to them. Herein, we report our experience with the management of a case of thyroid storm refractory to conventional treatment but responsive to therapeutic plasma exchange.
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Affiliation(s)
- Aaron J Wyble
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Steven C Moore
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Sean G Yates
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, Texas
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100
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Shoja MM, Nunez Lopez O, Okereke I. Acute Thyroid Storm Following Thymectomy: A Surprising Result of Undiagnosed Graves' Disease. Cureus 2018; 10:e3239. [PMID: 30410845 PMCID: PMC6209514 DOI: 10.7759/cureus.3239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Postoperative thyroid storm represents a diagnostic dilemma in patients with overlooked hyperthyroid state undergoing a nonthyroid surgery. We report a 30-year-old female with a history of mixed connective tissue disease who presented with an anterior mediastinal mass and underwent a thoracoscopic resection of the mass. On postoperative day 1, she had an acute change in mental status with fever, tachycardia and hypercapnic respiratory failure requiring intubation and mechanical ventilation. An elevated free thyroxine concentration and almost undetectable serum thyroid stimulating hormone suggested thyroid storm as the culprit. The patient was rendered euthyroid after initiation of therapy with propylthiouracil/methimazole, potassium iodide oral solution and systemic steroid. Histopathology of the resected anterior mediastinal mass showed thymic hyperplasia. In retrospect, the patient had hyperthyroid symptoms before surgery, but this diagnosis was overlooked. Non-thyroid surgeries can trigger thyroid storm in the setting of poorly controlled or overlooked hyperthyroidism. Although uncommon, thyroid storm should be considered in differential diagnosis of perioperative tachycardia and respiratory failure. We emphasize on the importance of preoperative thyroid workup in patients with tachycardia, palpitation, labile blood pressure, unexplained weight changes or poorly controlled anxiety. The significance of a proper preoperative assessment cannot be overestimated.
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Affiliation(s)
| | | | - Ikenna Okereke
- Surgery, University of Texas Medical Branch, Galveston, USA
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