2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

Hemodynamic Instability during Thyroidectomy in Graves' Disease

BACKGROUND

The aim of this study was to investigate the changes in vital signs and hemodynamic status that occur in patients during the intraoperative course of thyroidectomy in Graves' Disease (GD).

METHODS

A total of 71 patients were included in the study. Patients were directed to surgery when they had large goiters with compressive symptoms or suspicious nodules, were pregnant or lactating, were unresponsive or intolerant to antithyroid drugs (ATDs), or expressed a preference to have surgery. All patients scheduled for operations underwent surgery while in the euthyroid state.

RESULTS

Hemodynamic instability was observed in 18 patients during thyroidectomy. Disease duration, sample weight, and thyroid-stimulating hormone receptor antibodies (TRAb) levels were found to be effective on hemodynamic instability. Logistic regression analysis revealed an 11-fold increase in the instability risk in patients with a period of disease shorter than 21 months (P = 0.037). A TRAb value >11.5 increased the risk by 235fold (p < 0.001).

CONCLUSION

High levels of TRAb values and new onset of disease with shorter periods of ATDs use may be risk factors for hemodynamic instability during thyroidectomy. Patients with larger thyroid glands are at greater risk for instability during surgery. Those risks should be taken into account during surgery, and the surgical and anesthetic management of the patient should be made more carefully in concordance with the anesthesia team.

Epidemiology and factors associated with mortality of thyroid storm in Taiwan: a nationwide population-based study

Thyroid storm is a rare and life-threatening disease. However, its prevalence, incidence, and mortality rate in Chinese population are unknown. We performed a retrospective study using the Taiwan Health and Welfare Data. Patients admitted owing to thyrotoxicosis were divided into thyroid storm group and non-thyroid storm group. We assessed thyroid storm prevalence, incidence, complications, and mortality rate. Multiple Cox regression was performed to estimate the hazard ratio for the mortality risk. Overall, 1244 thyroid storm patients and 83,874 thyrotoxicosis patients without thyroid storm were included. Most thyroid storm patients were female (67.9%) with ages ranging from 30 to 44 years (33.4%), and most thyroid storm cases occurred during the summer season. The prevalence of thyroid storm was 1.48% (1244/83,874). The incidence rate of thyroid storm was 0.55 per 100,000 persons per year and 6.28 per 100,000 hospitalized patients per year. The overall 14-, 28-, and 90-day mortality rates of thyroid storm patients were 5.23%, 6.59%, and 8.12%, respectively. Thyroid storm, older age, male, and underlying ischemic stroke, myocardial infarction, heart failure, kidney disease, atrial fibrillation, depression, chronic obstructive pulmonary disease, diabetes mellitus, cancer, end stage renal diseases were associated with a significantly higher risk of mortality. In conclusion, the 90-day mortality rate of thyroid storm was high and was commonly associated with multiorgan failure and shock. Therefore, clinical physicians should identify thyroid storm and treat it accordingly.

Severe multisystem organ dysfunction in an adolescent with simultaneous presentation of Addison's and Graves' disease

OBJECTIVES

To report an unusual case of simultaneous presentation of Addison's and Graves' disease in an adolescent female previously diagnosed with type 1 diabetes (T1D) and Hashimoto's.

CASE PRESENTATION

A 15-year-old female with T1D and hypothyroidism presented to the emergency department with altered mental state, fever, and left arm weakness for one day. Clinical work-up revealed coexistent new-onset adrenal insufficiency and hyperthyroidism. Her clinical course was complicated by severe, life-threating multisystem organ dysfunction including neurologic deficits, acute kidney injury, and fluid overload. Thyroidectomy was ultimately performed in the setting of persistent signs of adrenal crises and resulted in rapid clinical improvement.

CONCLUSIONS

Endocrinopathy should be included in the differential diagnosis of altered mental status. This case additionally illustrates the challenges of managing adrenal insufficiency in the setting of hyperthyroidism and supports the use of thyroidectomy in this situation.

Very rare case of Graves' disease with resistance to methimazole: a case report and literature review

Background

Methimazole (MMI) is used to treat hyperthyroidism in Graves’ disease. It is rare to encounter patients in whom hyperthyroidism cannot be controlled using high doses of MMI.

Case presentation: A 21-year-old woman was referred to our hospital because of MMI-resistant Graves’ disease. Although her MMI dose had been increased to 120 mg/day, her serum thyroid hormone concentration was too high to be measured. Additional therapy with lithium carbonate, and then with dexamethasone and inorganic iodine, was initiated. After 14 days, the patient’s serum thyroid hormone concentration normalized, while she was taking 150 mg/day MMI, 800 mg/day lithium carbonate, 6 mg/day dexamethasone and 306 mg/day inorganic iodine, and total thyroidectomy was then performed. The patient was discharged 8 days after the thyroidectomy and experienced no major complications.

Conclusions

We have presented a rare case of Graves’ disease that was resistant to high-dose MMI. Combination therapy of MMI with lithium carbonate, dexamethasone and inorganic iodine may represent a therapeutic option for the preoperative preparation of patients with MMI-resistant Graves’ disease.

Medical treatment of thyrotoxicosis

Medical treatment is the primary therapeutic option for thyrotoxicosis/hyperthyroidism. Two groups of causes of thyrotoxicosis (i.e. thyrotoxicosis with hyperthyroidism and thyrotoxicosis without hyperthyroidism) need to be considered for therapeutic reasons. Herein we provide an updated review on the role of conventional medical therapies (i.e. β-blockers, antithyroid drugs [ATDs], corticosteroids, inorganic iodide, perchlorate, cholecystographic agents, lithium, cholestyramine) in the main causes of thyrotoxicosis, starting from the rationale subtending their clinical application.

Thyroid Storm: Unusual Presentation and Complication

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.

Crash Landing of Thyroid Storm: A Case Report and Review of the Role of Extra-Corporeal Systems

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.

Therapeutic Plasma Exchange in the Critically Ill Patient: Technology and Indications

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.

Recurrent Thyroid Storm Caused by a Complete Hydatidiform Mole in a Perimenopausal Woman

Background

Gestational trophoblastic disease (GTD) which includes hydatidiform mole, invasive mole, placental site trophoblastic tumor, and choriocarcinoma is a rare cause of hyperthyroidism due to excess production of placental human chorionic gonadotrophin hormone (hCG) by tumor cells. Molecular mimicry between hCG and thyroid stimulating hormone (TSH) leads to continuous stimulation of TSH receptor by extremely high levels of hCG seen in these tumors. Consequently, biochemical and clinical hyperthyroidism ensues and it is potentially complicated by thyrotoxic crisis which is fatal unless urgent therapeutic steps are undertaken. Case Description. We present a 49-year-old perimenopausal woman who presented with recurrent thyroid storm and high output cardiac failure. The initial workup revealed suppressed TSH, high-free thyroxine (FT4), and free triiodothyronine (FT3) levels with increased vascularity of the normal-sized thyroid on ultrasonography. She was managed with parenteral beta blockers, steroids, and high-dose carbimazole. Her lower abdominal tenderness led to further investigations which revealed tremendously elevated beta-hCG and a snow storm appearance on transabdominal ultrasound suggestive of GTD. She underwent curative surgery and was diagnosed with complete hydatidiform mole postoperatively by histology.

Conclusion

Recurrent thyroid crisis in gestational trophoblastic disease is an exceedingly rare presentation and that is highly fatal. This case highlights the importance of early detection and treatment of the etiology of thyrotoxicosis to eliminate mortality.

Therapeutic plasma exchange with albumin as a valuable method of preparing thyrotoxic patients for a life-saving thyroidectomy

Hyperthyroidism affects approximately 1.2% of the population and its routine treatment includes antithyroid drugs (ATDs), radioiodine and surgery. Management of patients with resistance or contraindications to ATDs who require thyroidectomy may be challenging. We present the experience of our department in preparing thyrotoxic patients for life-saving thyroidectomy by using therapeutic plasma exchange (TPE) with albumin: one patient with Graves' disease and previous history of agranulocytosis and cholestatic jaundice after ATDs and two patients with amiodarone-induced thyrotoxicosis. Five to six TPEs were applied to each patient resulting in a decrease of fT3 by 57% to 83%, fT4 by 21% to 60% and decrease/normalization of total thyroid hormones. All patients underwent surgery successfully. In case of drug-resistant thyrotoxicosis or contraindications to ATDs, TPE can be a valuable tool in preparing patients for surgery. Albumin used as a replacement fluid appears to be effective in ameliorating clinical and laboratory symptoms of thyrotoxicosis.

Usefulness of plasmapheresis in patients with severe complicated thyrotoxicosis

The standard treatment of complicated thyrotoxicosis and thyroid storm with the concomitant use of antithyroid medication, iodine, beta-blockers, and corticosteroids is successful in most cases. However, treatment options are limited when antithyroidal drugs cannot be used or in cases that are refractory to standard treatment. Plasmapheresis provides a safe and effective strategy when initial treatment fails, facilitating the transition to definitive treatments such as thyroidectomy. We present two adults with complicated thyrotoxicosis successfully treated with plasmapheresis as a bridge therapy to thyroidectomy or as an alternative to drug-induced toxicity.

Clinical and Laboratory Aspects of Insulin Autoantibody-Mediated Glycaemic Dysregulation and Hyperinsulinaemic Hypoglycaemia: Insulin Autoimmune Syndrome and Exogenous Insulin Antibody Syndrome

Autoimmune glycaemic dysregulation and hyperinsulinaemic hypoglycaemia mediated by insulin autoantibodies is an increasingly recognised but controversial phenomenon described in both exogenous insulin naïve (insulin autoimmune syndrome) and exposed (exogenous insulin antibody syndrome) individuals. There has been a significant proliferation of case reports, clinical studies and reviews in the medical literature in recent years which have collectively highlighted the discrepancy between experts in the field with regard to the nomenclature, definition, proposed pathophysiology, as well as the clinical and biochemical diagnostic criteria associated with the condition. The essential characteristics of the condition are glycaemic dysregulation manifesting as episodes of hyperglycaemia and unpredictable hyperinsulinaemic hypoglycaemia associated with high titres of endogenous antibodies to insulin. Although the hypoglycaemia is often life-threatening and initiation of targeted therapies critical, the diagnosis is often delayed and attributable to various factors including: the fact that existence of the condition is not universally accepted; the need to exclude surreptitious causes of hypoglycaemia; the diverse and often complex nature of the glycaemic dysregulation; and the challenge of diagnostic confirmation. Once confirmed, the available therapeutic options are expansive and the reported responses to these therapies have been variable. This review will focus on our evolving understanding, and the associated diagnostic challenges - both clinical and laboratory - of this complex condition.

Apathetic Thyroid Storm with Cardiorespiratory Failure, Pulmonary Embolism, and Coagulopathy in a Young Male with Graves' Disease and Myopathy

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.

Spinal anesthesia for urgent Cesarean section in a patient with uncontrolled hyperthyroidism due to Graves' disease - A case report

Background

Effective treatment of Graves’ disease during pregnancy is important because uncontrolled hyperthyroidism is associated with increased fetal and maternal morbidity and mortality. While there have been case reports of patients with Graves’ disease who failed to achieve euthyroid state during pregnancy, anesthesiologists rarely encounter patients with uncontrolled hyperthyroidism undergoing urgent Cesarean section.

Case

A 31-year-old pregnant patient had uncontrolled hyperthyroidism due to Graves’ disease despite medical treatment. Her signs and symptoms suggested fetal distress and aggravation of the disease, leading to hospitalization. After a failed induction for vaginal delivery, an urgent Cesarean section was performed under spinal anesthesia via an interlaminar approach using 9 mg of 0.5% heavy bupivacaine and 20 μg of fentanyl. It resulted in successful delivery, with no perioperative complications for the mother and neonate.

Conclusions

This case demonstrates that spinal anesthesia may provide clinical stability to patients with uncontrolled hyperthyroidism undergoing urgent Cesarean section.

Early administration of glucocorticoid for thyroid storm: analysis of a national administrative database

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.

Thyroid Storm in the ICU: A Retrospective Multicenter Study

OBJECTIVES

Thyroid storm represents a rare but life-threatening endocrine emergency. Only rare data are available on its management and the outcome of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management and in-ICU and 6-month survival rates of patients with those most severe thyroid storm forms requiring ICU admission.

DESIGN

Retrospective, multicenter, national study over an 18-year period (2000-2017).

SETTING

Thirty-one French ICUs.

PATIENTS

The local medical records of patients from each participating ICU were screened using the International Classification of Diseases, 10th Revision. Inclusion criteria were "definite thyroid storm," as defined by the Japanese Thyroid Association criteria, and at least one thyroid storm-related organ failure.

MEASUREMENTS AND MAIN RESULTS

Ninety-two patients were included in the study. Amiodarone-associated thyrotoxicosis and Graves' disease represented the main thyroid storm etiologies (30 [33%] and 24 [26%] patients, respectively), while hyperthyroidism was unknown in 29 patients (32%) before ICU admission. Amiodarone use (24 patients [26%]) and antithyroid-drug discontinuation (13 patients [14%]) were the main thyroid storm-triggering factors. No triggering factor was identified for 30 patients (33%). Thirty-five patients (38%) developed cardiogenic shock within the first 48 hours after ICU admission. In-ICU and 6-month postadmission mortality rates were 17% and 22%, respectively. ICU nonsurvivors more frequently required vasopressors, extracorporeal membrane of oxygenation, renal replacement therapy, mechanical ventilation, and/or therapeutic plasmapheresis. Multivariable analyses retained Sequential Organ Failure Assessment score without cardiovascular component (odds ratio, 1.22; 95% CI, 1.03-1.46; p = 0.025) and cardiogenic shock within 48 hours post-ICU admission (odds ratio, 9.43; 1.77-50.12; p = 0.008) as being independently associated with in-ICU mortality.

CONCLUSIONS

Thyroid storm requiring ICU admission causes high in-ICU mortality. Multiple organ failure and early cardiogenic shock seem to markedly impact the prognosis, suggesting a prompt identification and an aggressive management.

A case of thyroxine (T4) toxicosis complicated by thyroid storm with an unusual precipitant

Background:

Thyrotoxicosis, though commonly encountered in endocrinology practice in Nigeria, seldom presents solely as thyroxine (T4) toxicosis. Thyroid storm, a known life-threatening complication of thyrotoxicosis, can be precipitated by myriad factors. Fine need aspiration for cytology is not known, and has not been previously reported (to the best of our knowledge) to precipitate thyroid storm.

Case Presentation:

The case described is that of a 55 year old woman who presented with a neck swelling and features of hyperthyroidism, with biochemical parameters in keeping with T4 toxicosis. Investigating the patient necessitated a fine needle aspiration of the thyroid swelling. The patient thereafter developed hyper-metabolic features, and subsequently progressed to confusion and loss of consciousness few hours following the procedure. Close monitoring and medical management with anti-thyroid and other supportive therapies, resulted in an improved clinical condition.

Conclusion:

T4 toxicosis is a distinct biochemical entity of clinical significance. Physicians should bear in mind that micro-trauma from an investigation such as fine needle aspiration of the thyroid gland can tilt a thyrotoxic patient into thyroid storm, and this risk should be considered and prepared for by physicians and patients.

Surgical management of benign thyroid disease in children

Benign thyroid disease in children represents a wide spectrum of disease. While most benign thyroid disorders may be either monitored or managed medically, surgery is an important treatment, particularly for Graves' disease or large multinodular goiters. Multidisciplinary teams including specialists in pediatric endocrinology, genetics, radiology, pathology and surgery at high volume centers offer the safest and most effective management.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

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.

Effect of Plasma Exchange in Thyroid Storm With Consideration of Its Distribution Into the Extravascular Space

Plasma exchange (PE), which directly removes some plasma thyroid hormones, is a treatment option for thyroid storm. However, the effect of PE has not been accurately assessed yet. Here we assessed the effect of PE in a patient with thyroid storm while taking into consideration the distribution of thyroid hormones in the extravascular space. A 51-year-old woman with thyroid storm underwent 2 PE procedures at our hospital. By measuring changes in thyroid hormone levels in plasma, fresh frozen plasma (FFP) used, and waste fluid during each 2.5-hour PE procedure, we calculated the efficiency of thyroid hormone removal based on the hypothesis that total thyroid hormone content before and after PE is the same. During the patient’s first PE procedure, the estimated thyroxine (T₄) balance in the extravascular space (ΔX) was −70 μg, which corresponds to approximately 19% of T4 in the waste fluid. During the second PE procedure, ΔX was −131 μg, which corresponds to approximately 52% of T4 in the waste fluid. These data indicated that the source of removed T4 during PE varies. The amount of T₄ removed from the extravascular space should be taken into account during assessment of the effect of PE in thyroid storm.

Thyroid storm with encephalopathy and cardiovascular symptoms refractory to medical management in an adolescent

Thyroid storm (TS) is rare in pediatrics, most cases reported in literature responded well to medical therapy. We report the case of an adolescent female presented with TS refractory to anti-thyroid medical management. She had refractory hypertension, tachycardia, and progressive encephalopathy despite aggressive medical management. She underwent subtotal thyroidectomy after 2 weeks of failed medical management with a complete resolution of symptoms within days of surgery. We also learned sodium nitroprusside with its direct vasodilatory effect on conduit vessels, verapamil with its rate control properties, and labetalol with its dual sympathetic blockage property were beneficial in the management of this patient.

Thyroid Storm in a Toddler Presenting as a Febrile Seizure

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.

THYROID STORM WITH COMA IN A PATIENT WITH METASTATIC THYROID CARCINOMA AND GRAVES DISEASE: WON THE BATTLE BUT LOST THE WAR

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.

Thyroid storm after coronary artery bypass surgery: a case report

Background

Thyroid storm is a rare, life-threatening disease triggered by an acute event or trauma, such as surgery of the thyroid or another area, and infection. However, recent studies have shown that irregular use or discontinuation of antithyroid drugs is the most common cause of thyroid storm. A cardiovascular event caused by thyroid storm following coronary artery bypass graft (CABG) is high output heart failure with extreme tachycardia, which can be fatal. Thyroid storm after nonthyroidal surgery, especially CABG, has been rarely reported, with only one reported case until now. Herein, we present a case of thyroid storm onset in a patient who underwent CABG.

Case presentation

A 74-year-old woman with a history of antithyroid medication discontinuation against medical advice underwent urgent CABG. The patient exhibited extreme tachycardia postoperatively, which is highly suggestive of thyroid storm. Although a higher infection risk is an important consideration, a high-dose steroid was used to control the intractable tachycardia that did not respond to beta-blocker administration. Despite appropriate antibiotic treatment, the patient’s condition was exacerbated, and she developed multiple organ failure resulting from adult respiratory distress syndrome progression, and she died on day 8 after surgery.

Conclusions

Risk factors for thyroid storm after CABG and its treatment outcomes are rarely reported. Patients with a history of inappropriate antithyroid medication prescription should be in a euthyroid state before surgery. If surgery is imminent, anticipating thyroid storm and its treatment as well as a euthyroid state can improve recovery outcomes postoperatively.

Thyroid storm after chest trauma

Thyroid storm is an acute and severe complication of thyrotoxicosis. It is characterized by high fever, sweating, tachycardia, and often heart failure too. The objectives of the paper is to present the case of a patient with thyroid storm developed after the trauma of the chest at previously apparently healthy individuals, diagnosed on the basis of clinical preview and based on the diagnostic criteria according to Burch and Wartofsky. The most common complication is Mb. Graves - Basedow, but often associated with multi-nodose goiter. Thyroid storm is the most severe form of thyrotoxicosis with a mortality rate of 8 to 25 %. Case report. We present an interesting case from our practice: thyroid storm caused after chest trauma in apparently healthy people, but with unrecognized hyperthyroidism and thyroid gland nodule. Conclusion. The objectives of this presentation were to raise awareness of the association between signs and symptoms of thyroid storm that dominate the clinical picture and complicate the initial presentation and the evolution of the situation caused by trauma. The treatment of hyperthyroidism resulted in conversion in sinus rhythm, withdrawal of symptoms and signs heart failure, and normalization of artery pressure.

Intractable hiccups as a rare gastrointestinal manifestation in severe endocrine and metabolic crisis: case report and review of the literature

Diabetic ketoacidosis (DKA) and thyroid storm (TS) are severe metabolic and endocrine disorders. Both usually manifest with multiple systemic clinical signs and symptoms, and digestive symptoms, such as nausea and vomiting, are most common in these patients. Moreover, the presence of a concurrent severe or rare complication may worsen the condition or even cause death due to misdiagnosis, delayed diagnosis, or inappropriate treatment. The identification of these symptoms is usually closely related to the severity and prognosis of the disease. Although clinical prognosis might be improved by prompt diagnosis and aggressive treatment, some rare and insidious metabolic complications are difficult to identify early. Moreover, life-threatening gastrointestinal symptoms are very rare in patients with DKA and TS. Here, we report an inpatient diagnosed with DKA and Graves' disease who developed life-threatening intractable hiccups resulting in TS and respiratory failure during the treatment of DKA. In addition, we review the literature to discuss the possible underlying mechanism of intractable hiccups in the development of TS.

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

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.

Thyroid Storm with Multiorgan Failure Treated with Plasmapheresis

Background

Thyroid storm is a severe manifestation of thyrotoxicosis and can present with multiorgan failure. First line treatment of thyroid storm is directed towards decreasing thyroid hormone production and peripheral conversion of T4 to T3, and treating adrenergic symptoms. When medical therapy fails, plasmapheresis is an alternative treatment option. Here we present a patient with thyroid storm and multiorgan failure who was treated with plasmapheresis.

Case

A 50-year-old male with a history of hyperthyroidism, hypertension, and congestive heart failure presented to another hospital with fever and altered mentation. He was found to have pneumonia on imaging and was started on antibiotics. He developed shock complicated by atrial fibrillation with rapid ventricular rate which was treated with amiodarone. He was transferred to our hospital for further management. On arrival, TSH was <0.01 mIU/L, free T4 was >7 ng/dL and total T3 was 358 ng/dL. The endocrinology team determined he was in thyroid storm. His medical treatment of thyroid storm was aggressively titrated to maximal therapy. His hospital course was complicated by transaminitis, respiratory failure requiring intubation, shock requiring vasopressor support, kidney failure requiring continuous renal replacement therapy, and heart failure. Despite maximal anti-thyroid therapy, he had not improved clinically and T4 and T3 remained markedly elevated. A 4-day course of plasmapheresis was initiated resulting in marked lowering of T4 and T3 and clinical stability.

Conclusion

While current guidelines for plasmapheresis for thyroid storm recommend individualized decision making, no further clarification is provided on who would be a good candidate for the procedure. We present a patient with thyroid storm and multiorgan failure who was treated with plasmapheresis after failing maximal medical therapy. Given the significant improvement seen with plasmapheresis, endocrinologists should consider this mode of treatment earlier in the course of thyroid storm when patients are not improving with medical therapy alone.

Atypical presentation of thyroid storm: a diagnostic dilemma

Thyroid storm (accelerated hyperthyroidism) is an uncommon life-threatening emergency. The diagnosis is difficult and at times delayed owing to atypical presentation. Early diagnosis is the key to its successful management. We came across a patient who had presentations of acute abdomen but later diagnosed in thyroid storm. Multiorgan involvement leads all resuscitative measures futile and prevented us to salvage the patient.

The Delayed Diagnosis of Thyroid Storm in Patients with Psychosis

We herein report two cases of patients with thyroid storm with a delayed diagnosis due to psychosis. The patients were a 63-year-old woman with bipolar II disorder and a 37-year-old man with major depressive disorder. The psychoses in both patients were well controlled with medication. Although they both showed symptoms of thyrotoxicosis, the symptoms were ignored, presumably because the psychological manifestations of worsening of psychosis and thyroid storm are similar. When the mental or physical state of patients with psychosis changes, thyroid hormone levels should be measured for early treatment.

A Patient with Graves' Disease Scheduled for Thyroidectomy with High Risk for Thyroid Storm Caused by Severe Medication Nonadherence: Anaesthetic and Surgical Considerations

In patients with failed hormone regulation who are scheduled for indispensable total thyroidectomy, the risk of thyroid storm with severe end-organ complications has to be anticipated. This case report presents the successful surgical and anaesthesiological management of a patient with Graves' disease, without any signs of perioperative thyroid storm. Possible recommendations for treatment are presented.

Thyrotoxicosis-induced cardiomyopathy treated with venoarterial extracorporeal membrane oxygenation

A 37-year-old woman with no past medical history presented with longstanding untreated hyperthyroidism and consequentially developed thyrotoxicosis-induced cardiomyopathy. Upon admission, she was noted with a heart rate of 172 beats per minute and an EKG consistent with supraventricular tachycardia which was unresponsive to adenosine. Shortly after the initiation of a non-cardioselective beta-blocker for the treatment of persistent tachycardia, she developed profound cardiogenic shock refractory to vasopressors and inotropes. She was diagnosed with thyroid storm, which was ultimately attributed to Graves' Disease and controlled with propylthiouracil, potassium iodide drops, and hydrocortisone. Extracorporeal membrane oxygenation (ECMO) was successfully used as a temporizing measure while her thyroid hormone level normalized and cardiac function recovered. Patients with longstanding untreated hyperthyroidism may be dependent on the induced hyperadrenergic state to compensate for low-output cardiac failure, therefore it is important to exercise caution when initiating beta-adrenergic blockade. Given the expected disease time-course in cases of acute decompensation, ECMO remains a viable option for short-term mechanical circulatory support.

Coma in Thyroid Storm: Review of Aggregated English-Language Case Reports

CONTEXT

Coma is a serious manifestation of thyroid storm (TS) about which little is known.

OBJECTIVE

To describe the features, duration, treatment response, and prognosis of coma in the setting of TS.

DESIGN

Aggregate analysis of individual English-language case reports of coma in the setting of TS from 1935 to January 2019.

SETTING

Hospitals.

PATIENTS

Sixty-five cases were identified, 29 from case reports and 36 from case series.

INTERVENTIONS

Antithyroid drugs, corticosteroids, beta-blockers, iodine, intubation, plasmapheresis, antibiotics, thyroidectomy, radioiodine, dialysis, and l-carnitine.

MAIN OUTCOME MEASURES

Awakening and death rates overall and in relation to administered treatments, day of coma presentation, and time from coma onset; symptoms associated with coma; TS and coma scales; thyroid and cerebrospinal laboratory tests; electroencephalogram; brain imaging; and autopsy results.

RESULTS

Mortality was 38% in the setting of TS-related coma, 11% during the years 1978 to 2019 compared with 70% for 1935 to 1977. Both awakening and death commonly occurred within the first 2 days of coma onset. Reduction in total and free T4 values, and possibly also total T3 value, correlated with awakening from coma. Lower death rates were associated with use of antithyroid drugs, corticosteroids, beta-blockers, and intubation. Plasmapheresis was associated with awakening in 67% of cases but not with lower death rates.

CONCLUSIONS

Prognosis of coma associated with TS remains poor. Current guidelines for the early use of plasmapheresis in unresolving TS are advocated and should be considered urgently at the point of confusion or delirium in an effort to abort coma.

High-output congestive heart failure: a potentially deadly complication of thyroid storm

Hyperthyroidism, thyrotoxicosis and thyroid storm are a continuum of disease. A life-threatening and potentially fatal manifestation of thyrotoxicosis is thyroid storm. Thyroid storm is considered rare with an occurrence rate of 1-2% of all patients with hyperthyroidism, making a high index of suspicion important in the early recognition of this debilitating complication. We present the case of a 63-year-old female with a significant history of being non-compliant with her hyperthyroidism regimen and presented to the emergency department in severe respiratory distress. She was ultimately diagnosed with thyroid storm induced high-output congestive heart failure, intubated, had a cardiac arrest and was transferred to the intensive care unit in a guarded condition. Her hospital course was unremarkable and she was discharged on Day 12.

Clinical, Biochemical, Hematological, Endocrinological and Immunological Differences Between Graves' Disease Patients With and Without Thyroid Storm

Background

Thyroid storm (TS) is very rare, however, a life-threatening medical condition requiring emergency treatment. Since TS is rare, published case reports and seven unpublished cases of TS diagnosed at the researchers’ facilities were analyzed to make diagnostic criteria for TS in Japan. There are no reports on differences in backgrounds between Graves’ disease patients with and without TS, from a single research facility.

Methods

We retrospectively picked up patients who had been diagnosed as having Graves’ disease with and without TS, at National Center for Global Health and Medicine Kohnodai Hospital, between January 2010 and October 2018. According to the guideline for the diagnosis of Graves’ disease and TS presented by the Japan Thyroid Association, we diagnosed patients as having Graves’ disease with and without TS. We obtained clinical and laboratory data by using electronical medical records and database after showing the opt-out.

Results

We found 69 Graves’ disease patients without TS, and five Graves’ disease patients with TS. Graves’ disease patients with TS were significantly younger than those without TS. Graves’ disease patients with TS included a significantly higher percentage of male patients than those without TS. Body temperature and pulse rate in patients with TS were significantly higher than those without TS. Serum thyroid hormone levels and the titer of third-generation thyroid stimulating hormone receptor antibody in patients with TS were significantly higher than in those without TS. Neutrophilic leukocytosis together with eosinopenia, monocytopenia and lymphocytopenia were observed in patients with TS. Serum alkaline phosphatase level was significantly higher in patients with TS than in those without TS. Serum levels of triglyceride, high-density lipoprotein-cholesterol, and low-density lipoprotein-cholesterol in patients with TS were significantly lower than those without TS.

Conclusions

Our study demonstrated significant clinical, biochemical, hematological, endocrinological and immunological differences in Graves’ disease patients with TS compared to those without TS.

Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases

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 HbA_1C (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.

[Thyroid emergencies : Thyroid storm and myxedema coma]

Thyroid emergencies are rare life-threatening endocrine conditions resulting from either decompensated thyrotoxicosis (thyroid storm) or severe thyroid hormone deficiency (myxedema coma). Both conditions develop out of a long-standing undiagnosed or untreated hyper- or hypothyroidism, respectively, precipitated by an acute stress-associated event, such as infection, trauma, or surgery. Cardinal features of thyroid storm are myasthenia, cardiovascular symptoms, in particular tachycardia, as well as hyperthermia and central nervous system dysfunction. The diagnosis is made based on clinical criteria only as thyroid hormone measurements do not differentiate between thyroid storm and uncomplicated hyperthyroidism. In addition to critical care measures therapy focusses on inhibition of thyroid hormone synthesis and secretion (antithyroid drugs, perchlorate, Lugol's solution, cholestyramine, thyroidectomy) as well as inhibition of thyroid hormone effects in the periphery (β-blocker, glucocorticoids).Cardinal symptoms of myxedema coma are hypothermia, decreased mental status, and hypoventilation with risk of pneumonia and hyponatremia. The diagnosis is also purely based on clinical criteria as measurements of thyroid hormone levels do not differ between uncomplicated severe hypothyroidism and myxedema coma. In addition to substitution of thyroid hormones and glucocorticoids, therapy focusses on critical care measures to treat hypoventilation and hypercapnia, correction of hyponatremia and hypothermia.Survival of both thyroid emergencies can only be optimized by early diagnosis based on clinical criteria and prompt initiation of multimodal therapy including supportive measures and treatment of the precipitating event.

Weathering the Crisis: A Case of Thyroid Crisis with Propranolol-Induced Circulatory Collapse Successfully Treated with Therapeutic Plasma Exchange

Thyroid crisis is a life-threatening form of thyrotoxicosis characterized by multi-system dysfunction. Therapeutic plasma exchange has been reported to be effective in removing excessive circulating thyroid hormones. We present a 46-year-old female with recently diagnosed Graves’ disease associated with thyrotoxic cardiomyopathy admitted for thyroid crisis complicated by propranolol-induced circulatory collapse, acute kidney injury and ischemic hepatitis. The tachyarrhythmia was refractory to conventional therapy. Initiation of TPE resulted in rapid clinical and biochemical stabilization.

Comparison of Intra-Operative Vital Sign Changes during Total Thyroidectomy in Patients with Controlled and Uncontrolled Graves' Disease

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.

Thyroid storm: a case of haemodynamic failure promptly reversed by aggressive medical therapy with antithyroid agents and steroid pulse

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.

Diabetic Ketoacidosis Associated with Thyroxine (T₄) Toxicosis and Thyrotoxic Cardiomyopathy

Thyrotoxicosis and diabetic ketoacidosis (DKA) both may present as endocrine emergencies and may have devastating consequences if not diagnosed and managed promptly and effectively. The combination of diabetes mellitus (DM) with thyrotoxicosis is well known, and one condition usually precedes the other. Furthermore, thyrotoxicosis is complicated by some degree of cardiomyopathy in at least 5% de patients; but the coexistence of DKA, thyroxin (T₄) toxicosis, and acute cardiomyopathy is extremely rare. We describe a case of a man, previously diagnosed with DM but with no past history of thyroid disease, who presented with shock and severe DKA that did not improve despite optimal therapy. The patient evolved with acute pulmonary edema, elevated troponin levels, severe left ventricular systolic dysfunction, and clinical and laboratory evidence of thyroxin (T₄) toxicosis and thyrotoxic cardiomyopathy. Subsequently, the patient evolved favorably with general support and appropriate therapy for DKA and thyrotoxicosis (hydrocortisone, methimazole, Lugol’s solution) and was discharged a few days later.

Severe Mitral Regurgitation As a Result of Rupture of Mitral Valve Chordae Tendineae in a Patient With Graves Disease

Mitral valve prolapse is a common disorder, but severe mitral regurgitation (MR) as a result of rupture of mitral valve chordae tendineae is a rare manifestation of thyrotoxic heart disease. There are limited reports with respect to the onset of severe MR as a complication of Graves disease. We report a case of a 60-year-old woman with Graves disease and thyroid-associated ophthalmopathy as her past history. She had signs of congestive heart failure, a loud murmur as a result of MR, clinical cardiomegaly, and peripheral edema. Echocardiographic and angiographic data were consistent with moderate to severe MR. She also had thyrotoxicosis caused by the recurrence of Graves disease. She was taking methiamazole, a beta-blocker, hydrocortisone, and potassium iodide. Ultimately, thyroidectomy was performed to improve her hyperthyroid state. After normalization of her thyroid status, she continued to have moderate to severe MR, and mitral valve repair was performed. The present case had severe MR as a result of rupture of mitral valve chordae tendineae, which is considered rare in a patient with Graves disease.

ANNIVERSARY REVIEW: Antithyroid drug therapy: 70 years later

The thionamide antithyroid drugs were discovered in large part following serendipitous observations by a number of investigators in the 1940s who found that sulfhydryl-containing compounds were goitrogenic in animals. This prompted Prof. Edwin B Astwood to pioneer the use of these compounds to treat hyperthyroidism in the early 1940s and to develop the more potent and less toxic drugs that are used today. Despite their simple molecular structure and ease of use, many uncertainties remain, including their mechanism(s) of action, clinical role, optimal use in pregnancy and the prediction and prevention of rare but potentially life-threatening adverse reactions. In this review, we summarize the history of the development of these drugs and outline their current role in the clinical management of patients with hyperthyroidism.

2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism

Graves' disease (GD) is a systemic autoimmune disorder characterized by the infiltration of thyroid antigen-specific T cells into thyroid-stimulating hormone receptor (TSH-R)-expressing tissues. Stimulatory autoantibodies (Ab) in GD activate the TSH-R leading to thyroid hyperplasia and unregulated thyroid hormone production and secretion. Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, positive TSH-R-Ab, a hypervascular and hypoechoic thyroid gland (ultrasound), and associated orbitopathy. In GD, measurement of TSH-R-Ab is recommended for an accurate diagnosis/differential diagnosis, prior to stopping antithyroid drug (ATD) treatment and during pregnancy. Graves' hyperthyroidism is treated by decreasing thyroid hormone synthesis with the use of ATD, or by reducing the amount of thyroid tissue with radioactive iodine (RAI) treatment or total thyroidectomy. Patients with newly diagnosed Graves' hyperthyroidism are usually medically treated for 12-18 months with methimazole (MMI) as the preferred drug. In children with GD, a 24- to 36-month course of MMI is recommended. Patients with persistently high TSH-R-Ab at 12-18 months can continue MMI treatment, repeating the TSH-R-Ab measurement after an additional 12 months, or opt for therapy with RAI or thyroidectomy. Women treated with MMI should be switched to propylthiouracil when planning pregnancy and during the first trimester of pregnancy. If a patient relapses after completing a course of ATD, definitive treatment is recommended; however, continued long-term low-dose MMI can be considered. Thyroidectomy should be performed by an experienced high-volume thyroid surgeon. RAI is contraindicated in Graves' patients with active/severe orbitopathy, and steroid prophylaxis is warranted in Graves' patients with mild/active orbitopathy receiving RAI.

Combination therapy of ipilimumab and nivolumab induced thyroid storm in a patient with Hashimoto's disease and diabetes mellitus: a case report

BACKGROUND

Recently, immune checkpoint inhibitors have widely been used for the management of advanced melanoma. However, high-grade immune-related adverse events can occur, particularly with combination immunotherapy. We report a case of a patient with melanoma who developed thyroid storm following treatment with ipilimumab and nivolumab.

CASE PRESENTATION

An 85-year-old Japanese man with a history of malignant melanoma presented to our department with severe thyrotoxicosis and poor blood glucose control. He was already being treated for Hashimoto's disease and type 2 diabetes mellitus before the treatment for the melanoma. During admission, laboratory investigations revealed the following thyroid functions: thyroid-stimulating hormone below sensitivity, free triiodothyronine 31.7 pg/ml, and thyroglobulin 48,000 IU/ml. Thyroid-stimulating hormone receptor antibody was negative, and a ^99mTc-labeled thyroid scan revealed a markedly decreased uptake. He was treated with beta-blocker, orally administered potassium iodine, a relatively low dose of prednisolone, and insulin injection therapy to control his blood glucose, resulting in an improvement in thyroid function and his symptoms.

CONCLUSION

It might be important to be aware of the possibility of thyroid storm induced by immune checkpoint inhibitors.

Nonthionamide Drugs for the Treatment of Hyperthyroidism: From Present to Future

Hyperthyroidism is a common endocrine disease. Although thionamide antithyroid drugs are the cornerstone of hyperthyroidism treatment, some patients cannot tolerate this drug class because of its serious side effects including agranulocytosis, hepatotoxicity, and vasculitis. Therefore, nonthionamide antithyroid drugs (NTADs) still have an important role in controlling hyperthyroidism in clinical practice. Furthermore, some situations such as thyroid storm or preoperative preparation require a rapid decrease in thyroid hormone by combination treatment with multiple classes of antithyroid drugs. NTADs include iodine-containing compounds, lithium carbonate, perchlorate, glucocorticoid, and cholestyramine. In this narrative review, we summarize the mechanisms of action, indications, dosages, and side effects of currently used NTADs for the treatment of hyperthyroidism. In addition, we also describe the state-of-the-art in future drugs under development including rituximab, small-molecule ligands (SMLs), and monoclonal antibodies with a thyroid-stimulating hormone receptor (TSHR) antagonist effect.