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Seffah K, Lamptey R, Ibrahim S, Agyeman WY, Addo B. The Thyroid Forecast: A Case of a Thyroid Storm Diagnosed Under Unforeseen Circumstances. Cureus 2023; 15:e37707. [PMID: 37206496 PMCID: PMC10191387 DOI: 10.7759/cureus.37707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Hyperthyroidism and thyrotoxicosis are common conditions in clinical practice. Untreated, they are associated with several co-morbidities. One of these conditions, and arguably the most lethal, is the thyroid storm. Our case presentation is one of a young female who had previously been diagnosed with thyroid illness but was lost to follow-up, subsequently given a clean bill of health, and emerged with what would eventually be diagnosed as a thyroid storm. While the thyroid storm may pose some diagnostic challenges, it has come a long way in securing diagnostic tools. What remains is a tool for physicians and patients to stratify patients by their risk of developing a storm in the outpatient setting.
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Affiliation(s)
- Kofi Seffah
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Robert Lamptey
- Trauma and Emergency, Korle-Bu Teaching Hospital, Accra, GHA
| | - Sammudeen Ibrahim
- Graduate Medical Education, Piedmont Athens Regional Medical Center, Athens, USA
| | - Walter Y Agyeman
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Basilio Addo
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
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Oliinyk D, Augustin T, Rauch J, Koehler VF, Belka C, Spitzweg C, Käsmann L. Role of surgery to the primary tumor in metastatic anaplastic thyroid carcinoma: pooled analysis and SEER-based study. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04223-7. [PMID: 35960373 DOI: 10.1007/s00432-022-04223-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Anaplastic thyroid carcinoma (ATC) is an orphan disease with a fatal outcome. Surgery to the primary tumor in metastatic ATC is controversial. Determination of specific surgical techniques may help facilitate local control and, hence, beneficial overall and disease-specific survival. METHODS Using individualized patient data derived from our systematic review of literature and our single center study (n = 123), conducting a Surveillance, Epidemiology, and End Results register (SEER)-based study (n = 617) we evaluated surgery, its combination with systemic and local therapies in metastatic ATC. RESULTS Pooled cohort study showed surgery (p < 0.001), RT ≥ 30 Gy (p < 0.001), ChT (p < 0.001) and multimodal treatment (p = 0.014) to result in improved OS univariately. In the multivariate analysis, surgery (1.997 [1.162-3.433], p = 0.012) and RT ≥ 30 Gy (1.877 [1.232-2.843], p = 0.012) were independent predictors for OS. In SEER-based study of patients undergoing any tumor-directed treatment (n = 445) total thyroidectomy (p = 0.031), administration of ChT (p = 0.007), RT (p < 0.001), combination of surgery and RT ± ChT (p < 0.001) and multimodal treatment (p < 0.001) correlated with an improved DSS univariately. On the multivariate analysis, debulking surgery was an independent predictor for a worse outcome (HR 0.535, 95%CI 0.332-0.862, p = 0.010), whereas RT administration correlated with a longer DSS (HR 2.316, 95%CI 1.362-3.939, p = 0.002). Among operated patients from SEER register total thyroidectomy (p = 0.031), ChT (p = 0.007), RT (p < 0.001), combination of surgery and RT ± ChT (p < 0.001) and multimodal treatment (p < 0.001) correlated with an improved DSS in the univariate analysis, whereas debulking surgery was inversely correlated with the DSS (p < 0.001). On the multivariate analysis, debulking surgery was an independent predictor for a worse DSS (HR 0.535, 95%CI 0.332-0.862, p = 0.010), whilst RT administration correlated with a longer DSS (HR 2.316, 95%CI 1.362-3.939, p = 0.002). CONCLUSIONS Surgery to the primary tumor with the aim of R0/R1 resection, but not debulking, is associated with a significant OS and DSS benefit even in systemically metastasized disease.
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Affiliation(s)
- Dmytro Oliinyk
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Teresa Augustin
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Josefine Rauch
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | | | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336, Munich, Germany
| | - Christine Spitzweg
- Department of Internal Medicine IV, University Hospital, LMU Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336, Munich, Germany
| | - Lukas Käsmann
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, 80336, Munich, Germany.
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Mitchell-Brown F, Gates C. Myxedema coma: Recognition and treatment. Nursing 2022; 52:17-21. [PMID: 35752902 DOI: 10.1097/01.nurse.0000832344.83659.a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Myxedema coma (MC) develops from a long-standing, unrecognized, or untreated hypothyroidism. This article discusses the pathophysiology, clinical manifestations, treatment, and nursing considerations for patients with MC.
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Affiliation(s)
- Fay Mitchell-Brown
- Fay Mitchell-Brown is an associate professor at the California State University at Chico, where Claire Gates is a nursing student
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Deficiency of Thyroid Hormone Reduces Voltage-Gated Na + Currents as Well as Expression of Na +/K +-ATPase in the Mouse Hippocampus. Int J Mol Sci 2022; 23:ijms23084133. [PMID: 35456949 PMCID: PMC9031557 DOI: 10.3390/ijms23084133] [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] [Received: 02/28/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 02/04/2023] Open
Abstract
Mice lacking functional thyroid follicular cells, Pax8−/− mice, die early postnatally, making them suitable models for extreme hypothyroidism. We have previously obtained evidence in postnatal rat neurons, that a down-regulation of Na+-current density could explain the reduced excitability of the nervous system in hypothyroidism. If such a mechanism underlies the development of coma and death in severe hypothyroidism, Pax8−/− mice should show deficits in the expression of Na+ currents and potentially also in the expression of Na+/K+-ATPases, which are necessary to maintain low intracellular Na+ levels. We thus compared Na+ current densities in postnatal mice using the patch-clamp technique in the whole-cell configuration as well as the expression of three alpha and two beta-subunits of the Na+/K+-ATPase in wild type versus Pax8−/− mice. Whereas the Na+ current density in hippocampal neurons from wild type mice was upregulated within the first postnatal week, the Na+ current density remained at a very low level in hippocampal neurons from Pax8−/− mice. Pax8−/− mice also showed significantly decreased protein expression levels of the catalytic α1 and α3 subunits of the Na+/K+-ATPase as well as decreased levels of the β2 isoform, with no changes in the α2 and β1 subunits.
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Santos Argueta A, Doukas SG, Roy R. New-Onset Hypothyroidism Manifesting As Myxedema Coma: Fighting an Old Enemy. Cureus 2022; 14:e23881. [PMID: 35530928 PMCID: PMC9076032 DOI: 10.7759/cureus.23881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Myxedema coma (MC) is a rare manifestation of severe hypothyroidism. This is a true endocrine emergency that may remain unrecognized. We present a case of a 49-year-old man who presented to the emergency department with generalized weakness and confusion. He was found to have low temperature, bradycardia, hypoxia, hypotension, glucose of 59 mg/dL, normal electrolytes, thyroid-stimulating hormone of 154 IU/mL, and free T4 of 0.1 ng/dL. His anti-peroxidase antibody level was 99 IU/mL. Echocardiography revealed a normal ejection fraction and no evidence of pericardial effusion. On the basis of his presentation and laboratory findings, he was diagnosed with MC, intubated, and admitted to the intensive care unit. Thyroid hormone replacement and glucocorticoid treatment were initiated immediately. After the clinical improvement, the patient was extubated. MC is associated with a high mortality rate and requires prompt recognition and treatment. This rare case reminds us that MC might still be the first manifestation of primary hypothyroidism, although considered an “old enemy”.
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Tsang DA, Tan YH. Acute hypercapnic respiratory failure in thyroid storm and the role of plasma exchange. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:186-188. [PMID: 35373243 DOI: 10.47102/annals-acadmedsg.2021423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Denise Ann Tsang
- Department of Internal Medicine, Singapore General Hospital, Singapore
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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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[82/f-Confusion and recurrent falls : Preparation for the medical specialist examination: part 24]. Internist (Berl) 2021; 62:136-140. [PMID: 33606041 DOI: 10.1007/s00108-021-00952-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
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Endokrinologische Notfälle. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00766-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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Vrachimis A, Iakovou I, Giannoula E, Giovanella L. ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of thyroid nodules and cancer. Eur J Endocrinol 2020; 183:G41-G48. [PMID: 32438345 PMCID: PMC7938009 DOI: 10.1530/eje-20-0269] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/20/2020] [Indexed: 12/24/2022]
Abstract
Most patients with thyroid nodules and thyroid cancer (TC) referred for diagnostic work-up and treatment are not considered at higher risk of infection from SARS-CoV-2 compared to the general population. On the other hand, healthcare resources should be spared to the maximum extent possible during a pandemic. Indeed, while thyroid nodules are very common, only a small percentage are cancerous and, in turn, most thyroid cancers are indolent in nature. Accordingly, diagnostic work-up of thyroid nodules, thyroid surgery for either benign or malignant thyroid nodules and radioiodine treatment for differentiated thyroid cancers may be safely postponed during SARS-CoV-2 pandemic. Appropriate patient counselling, however, is mandatory and red flags should be carefully identified prompting immediate evaluation and treatment as appropriate. For these selected cases diagnostic work-up (e.g. ultrasound, scintigraphy, fine-needle aspiration), surgery and radioiodine therapy may proceed despite the threat of SARS-CoV-2 infection and COVID-19, after an individual risk-benefit analysis.
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Affiliation(s)
- Alexis Vrachimis
- Department of Nuclear Medicine, German Oncology Center, University Hospital of the European University, Limassol, Cyprus
- Correspondence should be addressed to A Vrachimis;
| | - Ioannis Iakovou
- Academic Department of Nuclear Medicine, University Hospital AHEPA, School of Medicine, Thessaloniki, Greece
- Academic Department of Nuclear Medicine, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Evanthia Giannoula
- Academic Department of Nuclear Medicine, University Hospital AHEPA, School of Medicine, Thessaloniki, Greece
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Competence Centre for Thyroid Diseases, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Clinic for Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland
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Abstract
The diagnosis of hypothyroidism is primarily based on clinical signs and symptoms as well as measurement of thyroid-stimulating hormone (TSH) concentration. Subclinical hypothyroidism is characterized by elevated TSH with normal serum free thyroxine (fT4) and triiodothyronine (fT3) levels, while in manifest hypothyroidism serum fT4 and fT3 levels are reduced. Common causes of primary hypothyroidism are autoimmune thyroiditis as well as therapeutic interventions, such as thyroid surgery or radioiodine therapy. Signs and symptoms of hypothyroidism include fatigue, bradycardia, constipation and cold intolerance. In subclinical hypothyroidism, symptoms may be absent. Initiation of levothyroxine (T4) therapy not only depends on the level of TSH elevation, but also on other factors, such as patient age, presence of pregnancy or comorbidities. Treatment of patients with subclinical hypothyroidism is still a controversial topic. In general, thyroid hormone replacement therapy in non-pregnant adults ≤ 70 years is clearly indicated if the TSH concentration is >10 mU/l. Standard of care for treatment of hypothyroidism is T4 monotherapy. The biochemical treatment goal for T4 replacement in primary hypothyroidism is a TSH level within the reference range (0.4-4.0 mU/l). In contrast, in secondary hypothyroidism, serum fT4 levels are the basis for adjusting thyroid hormone dosage. Inadequate replacement of T4 resulting in subclinical or even manifest hyperthyroidism should urgently be avoided. T4/liothyronine (T3) combination therapy is still a matter of debate and not recommended as standard therapy, but may be considered in patients with persistence of symptoms, despite optimal T4 treatment, based on expert opinion.
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Cadus C, Mehlig A, Minder A. [Rare Complication of a Common Disease: Thyroid and Epileptic Seizures]. PRAXIS 2018; 107:1409-1412. [PMID: 31166874 DOI: 10.1024/1661-8157/a003144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Rare Complication of a Common Disease: Thyroid and Epileptic Seizures Abstract. A myxedema crisis is a life-threatening complication of hypothyroidism (mortality 20-25 %). The diagnosis is made on clinical grounds and thyroid function tests. Treatment with levothyroxine (possibly combined with T3) should be instituted immediately, along with glucocorticoids, until co-existing adrenal insufficiency has been ruled out. Supportive measures and treatment of underlying diseases should be implemented. We are presenting the case of a patient with myxedema crisis complicated by tonic-clonic seizures and severe hyponatremia as first manifestation of primary hypothyroidism.
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Affiliation(s)
- Cordula Cadus
- 1 Medizinische Universitätsklinik, Kantonsspital Baselland, Standort Liestal
| | - Annekathrin Mehlig
- 1 Medizinische Universitätsklinik, Kantonsspital Baselland, Standort Liestal
| | - Anna Minder
- 2 Abteilung Endokrinologie/Diabetologie, Kantonsspital Baselland, Standort Liestal
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