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Feldkamp JD, Feldkamp J. Indications for Intravenous T3 and T4. Horm Metab Res 2024. [PMID: 38698631 DOI: 10.1055/a-2318-5156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Therapy with thyroid hormones normally is restricted to substitution therapy of patients with primary or secondary hypothyroidism. Typically, thyroid hormones are given orally. There are few indications for intravenous use of thyroid hormones. Indications for parenteral application are insufficient resorption of oral medications due to alterations of the gastrointestinal tract, partial or total loss of consciousness, sedation in the intensive care unit or shock. In almost all cases, levothyroxine is the therapy of choice including congenital hypothyroidism. In preterm infants with an altered thyroid hormone status, studies with thyroid hormones including intravenous liothyronine showed a normalisation of T3 levels and in some cases an amelioration of parameters of ventilation. A benefit for mortality or later morbidity could not be seen. Effects on neurological improvements later in life are under discussion. Decreased thyroid hormone levels are often found after cardiac surgery in infants and adults. Intravenous therapy with thyroid hormones improves the cardiac index, but in all other parameters investigated, no substantial effect on morbidity and mortality could be demonstrated. Oral liothyronine therapy in these situations was equivalent to an intravenous route of application. In myxoedema coma, intravenous levothyroxine is given for 3 to 10 days until the patient can take oral medication and normal resorption in the gastrointestinal tract is achieved by restoring at least peripheral euthyroidism. Intravenous levothyroxine is the standard in treating patients with myxoedema coma. A protective effect on the heart of i.v. levothyroxine in brain-dead organ donors may be possible.
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Affiliation(s)
- Jasper David Feldkamp
- Division of Hematology, Oncology, and Cancer Immunology, Charite Medical Faculty Berlin, Berlin, Germany
| | - Joachim Feldkamp
- Klinikum Bielefeld, Academic Department of General Internal Medicine, Endocrinology and Diabetes, Infectiology, Bielefeld University, Medical School and University Medical Center East Westphalia-Lippe, Bielefeld, Germany
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Elmenyar E, Aoun S, Al Saadi Z, Barkumi A, Cander B, Al-Thani H, El-Menyar A. Data Analysis and Systematic Scoping Review on the Pathogenesis and Modalities of Treatment of Thyroid Storm Complicated with Myocardial Involvement and Shock. Diagnostics (Basel) 2023; 13:3028. [PMID: 37835772 PMCID: PMC10572182 DOI: 10.3390/diagnostics13193028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Thyroid storm (TS) is a rare and fatal endocrine emergency that occurs due to undiagnosed and inadequately treated hyperthyroidism after stressful conditions in patients with thyroid disorders. The objective of this systematic scoping review was to better understand the pathophysiology of TS and its complications, in terms of myocardial affection, tachyarrhythmia, and cardiogenic shock. In addition, we explored the pharmacological, mechanical, and surgical treatments for TS. We also evaluated the outcomes of TS according to sex and cardiac involvement. Additionally, analytical analysis was performed on the selected data. A literature review of peer-reviewed journals was carried out thoroughly using medical terms, MeSH on PubMed, Google Scholar, and combinations such as thyrotoxicosis-induced cardiomyopathy, thyroid storm, cardiogenic shock, myocardial infarction, endocrine emergency, Burch-Wartofsky score, extracorporeal circulatory support, and thyroidectomy. A total of 231 papers were eligible (2 retrospective studies, 5 case series, and 224 case reports) with a total of 256 TS patients with cardiac involvement between April 2003 and August 2023. All age groups, sexes, patients with TS-induced cardiomyopathy, non-atherosclerotic myocardial infarction, tachyarrhythmia, heart failure, shock, and different forms of treatment were discussed. Non-English language articles, cases without cardiac involvement, and cases in which treatment modalities were not specified were excluded. Female sex was predominant, with 154 female and 102 male patients. Approximately 82% of patients received beta-blockers (BBs), 16.3% were placed on extracorporeal membrane oxygenation (ECMO) support, 16.3% received therapeutic plasma exchange (TPE), and 13.8% underwent continuous renal replacement therapy (CRRT), continuous venovenous hemofiltration (CVVHD), or dialysis. Overall, 18 females and 16 males died. BB-induced circulatory collapse, acute renal failure, CRRT, and ventricular fibrillation were significantly associated with mortality. Awareness of TS and not only thyrotoxicosis is vital for timely and appropriate treatment. The early diagnosis and management of TS in cardiac settings, including pharmacological, mechanical, and surgical modalities, can save high-risk patients. Sex matters in the presentation, treatment, and mortality of this population. However, further large-scale, and well-designed studies are required.
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Affiliation(s)
- Eman Elmenyar
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Sarah Aoun
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Zain Al Saadi
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Ahmed Barkumi
- Faculty of Medicine, Internship, Bahcesehir University, Istanbul 34734, Turkey; (E.E.); (S.A.); (Z.A.S.); (A.B.)
| | - Basar Cander
- Department of Emergency Medicine, Kanuni Sultan Süleyman Training & Research Hospital, Istanbul 34303, Turkey;
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha 3050, Qatar;
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad General Hospital, Doha 3050, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha 24144, Qatar
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3
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Bourcier S, Coutrot M, Ferré A, Van Grunderbeeck N, Charpentier J, Hraiech S, Azoulay E, Nseir S, Aissaoui N, Messika J, Fillatre P, Persichini R, Carreira S, Lautrette A, Delmas C, Terzi N, Mégarbane B, Lascarrou JB, Razazi K, Repessé X, Pichereau C, Contou D, Frérou A, Barbier F, Ehrmann S, de Montmollin E, Sztrymf B, Morawiec E, Bigé N, Reuter D, Schnell D, Ellrodt O, Dellamonica J, Combes A, Schmidt M. Critically ill severe hypothyroidism: a retrospective multicenter cohort study. Ann Intensive Care 2023; 13:15. [PMID: 36892784 PMCID: PMC9998819 DOI: 10.1186/s13613-023-01112-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/19/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Severe hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes 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 these patients. METHODS We conducted a retrospective, multicenter study over 18 years in 32 French ICUs. The local medical records of patients from each participating ICU were screened using the International Classification of Disease 10th revision. Inclusion criteria were the presence of biological hypothyroidism associated with at least one cardinal sign among alteration of consciousness, hypothermia and circulatory failure, and at least one SH-related organ failure. RESULTS Eighty-two patients were included in the study. Thyroiditis and thyroidectomy represented the main SH etiologies (29% and 19%, respectively), while hypothyroidism was unknown in 44 patients (54%) before ICU admission. The most frequent SH triggers were levothyroxine discontinuation (28%), sepsis (15%), and amiodarone-related hypothyroidism (11%). Clinical presentations included hypothermia (66%), hemodynamic failure (57%), and coma (52%). In-ICU and 6-month mortality rates were 26% and 39%, respectively. Multivariable analyses retained age > 70 years [odds ratio OR 6.01 (1.75-24.1)] Sequential Organ-Failure Assessment score cardiovascular component ≥ 2 [OR 11.1 (2.47-84.2)] and ventilation component ≥ 2 [OR 4.52 (1.27-18.6)] as being independently associated with in-ICU mortality. CONCLUSIONS SH is a rare life-threatening emergency with various clinical presentations. Hemodynamic and respiratory failures are strongly associated with worse outcomes. The very high mortality prompts early diagnosis and rapid levothyroxine administration with close cardiac and hemodynamic monitoring.
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Affiliation(s)
- Simon Bourcier
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France
| | - Maxime Coutrot
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France
| | - Alexis Ferré
- Intensive Care Unit, Versailles Hospital, Le Chesnay, France
| | | | - Julien Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, APHP, Paris, France
| | - Sami Hraiech
- Réanimation des Détresses Respiratoires et des Infections Sévères, Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Saad Nseir
- Médecine Intensive-Réanimation, CHU de Lille, 59000, Lille, France.,INSERM U1285, Université de Lille, CNRS, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, 59000, Lille, France
| | - Nadia Aissaoui
- Department of Critical Care Unit, Hôpital Européen Georges-Pompidou (HEGP), APHP, Paris, France
| | - Jonathan Messika
- Medico-Surgical Intensive Care Unit, APHP. Nord-Université Paris Cité, Hôpital Louis Mourier, 92700, Colombes, France
| | - Pierre Fillatre
- Medical-Surgical Intensive Care Unit, CH de Saint-Brieuc, Saint-Brieuc, France
| | - Romain Persichini
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) de La Réunion, Felix-Guyon Hospital, Saint-Denis, La Réunion, France
| | - Serge Carreira
- Medical-Surgical Intensive Care Unit, Saint-Camille Hospital, Bry-sur-Marne, France
| | | | - Clément Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, 1 Avenue Jean Poulhes, 31059, Toulouse, France.,REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
| | - Nicolas Terzi
- Department of Medical Intensive Care, CHU de Grenoble Alpes, Grenoble, France
| | - Bruno Mégarbane
- Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France
| | | | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, AP-HP, CHU Henri Mondor, DHU A-TVB, Créteil, France
| | - Xavier Repessé
- Intensive Care Unit, University Hospital Ambroise-Paré, APHP, Boulogne-Billancourt, France
| | - Claire Pichereau
- Intensive Care Unit, Poissy Saint-Germain-en-Laye Hospital, Poissy, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Aurélien Frérou
- Medical Intensive Care Unit, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - François Barbier
- Medical Intensive Care Unit, CH Regional d'Orléans, Orléans, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CHRU Tours, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France.,INSERM, Centre d'étude Des Pathologies Respiratoires, U1100, Tours, France.,Université de Tours, Tours, France
| | | | - Benjamin Sztrymf
- Service de Réanimation Polyvalente et Surveillance Continue, AP-HP, Hôpital Antoine Béclère, 157 rue de la porte de Triveaux, 92140, Clamart, France
| | - Elise Morawiec
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Hôpital de la Pitié-Salpêtrière, APHP, Paris, France
| | - Naïke Bigé
- Medical Intensive Care Unit, Hôpital Saint-Antoine, APHP, Paris, France
| | - Danielle Reuter
- Medical-Surgical Intensive Care Unit, CH Sud Francilien, Corbeil, France
| | - David Schnell
- Service de Réanimation Polyvalente, CH d'Angoulême, Angoulême, France
| | - Olivier Ellrodt
- Département de Médecine Intensive, Groupe Hospitalier Sud Île-de-France, Hôpital de Melun, Melun, France
| | - Jean Dellamonica
- Service de Médecine Intensive Réanimation, Hôpital Archet 1, Centre Hospitalier Universitaire de Nice, UR2CA Université Cote d'Azur, Nice, France
| | - Alain Combes
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France.,Medecine Intensive Reanimation, Institute of Cardiometabolism and Nutrition, Sorbonne Universités, INSERM, UMRS_1166-ICAN, Hôpital de la Pitié-Salpêtrière, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France. .,Medecine Intensive Reanimation, Institute of Cardiometabolism and Nutrition, Sorbonne Universités, INSERM, UMRS_1166-ICAN, Hôpital de la Pitié-Salpêtrière, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
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5
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Alsalama F, Alzaabi S, Salloum C, Younes MA, Bader F, Ghalib H, Atallah B. Ventricular arrhythmias, antiarrhythmic therapy and thyroidal illness in advanced heart failure: a case report and review of the literature. DRUGS & THERAPY PERSPECTIVES 2023. [DOI: 10.1007/s40267-023-00985-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Mydske S, Haukeland IC, Godø AH, Grytaas MA, Vold JH, Hartwig A. En kvinne i 20-årene med paranoide vrangforestillinger. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:22-0243. [DOI: 10.4045/tidsskr.22.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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7
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Kaneko M, Ohara K, Shikata H. A case of fatal myxedema coma with electrocardiogram Osborne J-wave in a patient initially diagnosed with hypothyroidism. Endocr J 2022; 69:1109-1115. [PMID: 35400676 DOI: 10.1507/endocrj.ej21-0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Myxedema coma is a life-threatening endocrine emergency with a high mortality rate resulting from severe insufficiency of thyroid hormones. Intravenous levothyroxine replacement is considered the standard therapy for myxedema coma in many countries. In Japan, however, although there are diagnostic criteria highly suggestive or diagnostic for myxedema coma, no management strategy has been established, despite the availability of levothyroxine. Here we report a 75-year-old man with a history of Alzheimer's disease and schizophrenia who developed somnolence and generalized edema. Except for a pulse rate of 60 bpm, his vital signs and blood oxygen level were stable. Thyroid studies showed an elevated serum thyrotropin level of 219.2 μU/mL and a decreased serum free-thyroxine level of 0.15 ng/dL. On this basis he was diagnosed as having hypothyroidism rather than being highly suggestive for myxedema coma. Daily oral levothyroxine 25 μg was initiated and increased to 50 μg 3 days later. Seven days after being started on levothyroxine, the patient suddenly developed impaired consciousness, hypoxemia, hypotension, hypothermia, and hyponatremia. Electrocardiography revealed junctional bradycardia with Osborne J-wave. Myxedema coma was therefore diagnosed. He went into cardiac arrest in the emergency room but was resuscitated. Despite subsequent intravenous administration of hydrocortisone and levothyroxine, as well as intensive supportive care, he eventually died 12 hours after hospital admission. This case illustrates some of the challenges associated with the management of patients with signs highly suggestive/diagnostic of myxedema coma, including the optimal loading dosage and intervention timing of thyroid hormone replacement.
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Affiliation(s)
- Masahiko Kaneko
- Department of Internal Medicine, Uwajima City Hospital, Ehime 798-8510, Japan
| | - Kentarou Ohara
- Postgraduate Clinical Training Center, Uwajima City Hospital, Ehime 798-8510, Japan
| | - Hisaharu Shikata
- Department of Internal Medicine, Uwajima City Hospital, Ehime 798-8510, Japan
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8
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Park K, Jang JY, Lee S. The Occurrence of a Thyroid Storm in a Patient with Recurrent Refractory Peptic Ulcer: A Case Report. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A thyroid storm is a rare complication of hyperthyroidism. Although a thyroid storm rarely presents with symptoms similar to those of an acute abdomen, and in cases where emergency surgery is needed, the thyroid function test is not performed routinely. In this study, we report a case in which hyperthyroidism was diagnosed after surgery in a patient with recurrent refractory peptic ulcer disease. Although peptic ulcer disease and hyperthyroidism rarely coexist, when the patient's initial condition was reviewed in the Emergency Department, the findings were reasonable for panperitonitis due to peptic ulcer perforation, which is considered as a condition suitable for a thyroid storm. This isolated case indicates a logical leap in the correlation between peptic ulcer and thyroid storm. In recurrent refractory peptic ulcer disease, the thyroid function test may be helpful as a routine laboratory test before emergency surgery.
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Chua MWJ, Chua MWJ. A Patient with Recurrent Myxedema Coma: What Was the Missing Link? Am J Med 2022; 135:393-396. [PMID: 34597614 DOI: 10.1016/j.amjmed.2021.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/01/2022]
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10
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Ito H, Fukuda K, Ashida K, Nagayama A, Sako T, Mizuochi K, Kabashima M, Yoshinobu S, Iwata S, Hasuzawa N, Hayashi S, Akashi T, Nomura M. Case Report: Myxedema Coma Caused by Immunoglobulin A Vasculitis in a Patient With Severe Hypothyroidism. Front Immunol 2022; 13:838739. [PMID: 35251034 PMCID: PMC8895252 DOI: 10.3389/fimmu.2022.838739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
Myxedema coma is a critical disorder with high mortality rates. Disruption of the compensatory mechanism for severe and long-term hypothyroidism by various causes leads to critical conditions, including hypothermia, respiratory failure, circulatory failure, and central nervous system dysfunction. Infectious diseases, stroke, myocardial infarction, sedative drugs, and cold exposure are considered the main triggers for myxedema coma. A 59-year-old Japanese woman presented with bilateral painful purpura on her lower legs. She was diagnosed with coexisting immunoglobulin A (IgA) vasculitis and severe IgA vasculitis with nephritis and was consequently treated with intravenous methylprednisolone (125 mg/day). However, she rapidly developed multiple organ failure due to the exacerbation of severe hypothyroidism, i.e., myxedema. Her condition improved significantly following oral administration of prednisolone along with thyroxine. There was a delayed increase in the serum free triiodothyronine level, while the serum free thyroxine level was quickly restored to normal. Rapid deterioration of the patient’s condition after admission led us to diagnose her as having myxedema coma triggered by IgA vasculitis. Hence, clinicians should be aware of the risks of dynamic exacerbations in patients with hypothyroidism. Furthermore, our study suggested that combination therapy with thyroxine and liothyronine might prove effective for patients with myxedema coma, especially for those who require high-dose glucocorticoid administration.
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Affiliation(s)
- Hiroshi Ito
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
- Department of Diabetology, Shimada Hospital, Ogori, Japan
| | - Kenzo Fukuda
- Department of Diabetology, Shimada Hospital, Ogori, Japan
- Department of Intensive Care Medicine, Imamura Hospital, Tosu, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
- Department of Diabetology, Shimada Hospital, Ogori, Japan
- *Correspondence: Kenji Ashida ,
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tomoki Sako
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kouichiro Mizuochi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Masaharu Kabashima
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Satoko Yoshinobu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Shimpei Iwata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Nao Hasuzawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Sumika Hayashi
- Department of Diabetology, Shimada Hospital, Ogori, Japan
| | | | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
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Raguthu CC, Gajjela H, Kela I, Kakarala CL, Hassan M, Belavadi R, Gudigopuram SVR, Sange I. Cardiovascular Involvement in Thyrotoxicosis Resulting in Heart Failure: The Risk Factors and Hemodynamic Implications. Cureus 2022; 14:e21213. [PMID: 35186521 PMCID: PMC8845451 DOI: 10.7759/cureus.21213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/05/2022] Open
Abstract
Thyrotoxicosis is a clinical syndrome with persistently elevated concentrations of free triiodothyronine, free thyroxine, or both, which correlates with an increased thyroid metabolic function. This article has discussed the direct effect of increased thyroid hormone on the heart, as the thyroid hormone physiologically exhibits a close harmony with hormones of the cardiovascular system. This action can lead to disturbances in hemodynamic stability, exacerbating the possibility of developing complications such as heart failure and life-threatening arrhythmias. This article has also explored the multifaceted pathogenesis of thyrotoxicosis and various pharmacological treatment options, including beta-blockers and anti-thyroid drugs. This article has reviewed numerous studies that have concluded that the main goal of therapy should always aim to normalize thyroid hormone levels based on the etiology of the thyrotoxicosis, although cardiovascular conditions are associated with a higher rate of mortality.
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12
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Wolff TM, Dietrich JW, Müller MA. Optimal Hormone Replacement Therapy in Hypothyroidism - A Model Predictive Control Approach. Front Endocrinol (Lausanne) 2022; 13:884018. [PMID: 35813623 PMCID: PMC9263720 DOI: 10.3389/fendo.2022.884018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
In this paper, we address the problem of optimal thyroid hormone replacement strategy development for hypothyroid patients. This is challenging for the following reasons. First, it is difficult to determine the correct dosage leading to normalized serum thyroid hormone concentrations of a patient. Second, it remains unclear whether a levothyroxine L-T4) monotherapy or a liothyronine/levothyroxine (L-T3/L-T4) combined therapy is more suitable to treat hypothyroidism. Third, the optimal intake frequency of L-T3/L-T4 is unclear. We address these issues by extending a mathematical model of the pituitary-thyroid feedback loop to be able to consider an oral intake of L-T3/L-T4. A model predictive controller (MPC) is employed to determine optimal dosages with respect to the thyroid hormone concentrations for each type of therapy. The results indicate that the L-T3/L-T4 combined therapy is slightly better (in terms of the achieved hormone concentrations) to treat hypothyroidism than the L-T4 monotherapy. In case of a specific genetic variant, namely genotype CC in polymorphism rs2235544 of gene DIO1, the simulation results suggest that the L-T4 monotherapy is better to treat hypothyroidism. In turn, when genotype AA is considered, the L-T3/L-T4 combined therapy is better to treat hypothyroidism. Furthermore, when genotype CC of polymorphism rs225014 (also referred to as c.274A>G or p.Thr92Ala) in the DIO2 gene is considered, the outcome of the L-T3/L-T4 combined therapy is better in terms of the steady-state hormone concentrations (for a triiodothyronine setpoint at the upper limit of the reference range of healthy individuals). Finally, the results suggest that two daily intakes of L-T3 could be the best trade-off between stable hormone concentrations and inconveniences for the patient.
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Affiliation(s)
- Tobias M. Wolff
- Institute of Automatic Control, Leibniz University Hannover, Hannover, Germany
- *Correspondence: Tobias M. Wolff,
| | - Johannes W. Dietrich
- Diabetes, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
- Diabetes Centre Bochum-Hattingen, St. Elisabeth-Hospital Blankenstein, Hattingen, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Bochum, Germany
| | - Matthias A. Müller
- Institute of Automatic Control, Leibniz University Hannover, Hannover, Germany
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Ruggiero RA, Iqbal QZ, Akram A, Dendy J, Zaidan J. A Rare Case of Hypoparathyroidism and Myxedema Coma in a Patient With Diamond-Blackfan Anemia. Cureus 2021; 13:e19941. [PMID: 34976531 PMCID: PMC8711578 DOI: 10.7759/cureus.19941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2021] [Indexed: 11/05/2022] Open
Abstract
Diamond-Blackfan anemia (DBA) is a rare genetic condition that presents due to bone marrow failure caused by a dysfunction in ribosomal biogenesis and function. The patients would often require chronic transfusions as treatment, which puts them at high risk for the development of secondary hemochromatosis. This secondary hemochromatosis results in endocrinopathies due to iron deposition into the endocrine glands. We present an interesting case report of a female patient with multiple endocrinopathies due to secondary hemochromatosis resulting from chronic transfusion therapy. Her endocrinopathies included hypothyroidism complicated by myxedema coma and, interestingly, hypoparathyroidism, which has seldom been reported in DBA patients. Early diagnosis and precise treatment of life-threatening conditions like myxedema coma in DBA patients can avoid morbidity and mortality.
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Yoshinaka A, Akatsuka M, Yamamoto S, Yamakage M. Sudden cardiac arrest associated with myxedema coma due to undiagnosed hypothyroidism: a case report. BMC Endocr Disord 2021; 21:229. [PMID: 34789203 PMCID: PMC8596363 DOI: 10.1186/s12902-021-00894-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Myxedema coma, which occurs due to hypothyroidism, is a rare and life-threatening condition. Some patients have hemodynamic dysfunction, which consequently leads to cardiac arrest. The rarity of this condition makes it difficult to determine the cause of cardiac arrest. It is important to diagnose myxedema coma based on clinical findings, including physical examination and laboratory parameters. We present a case of undiagnosed and untreated hypothyroidism that initially caused myxedema coma and then led to cardiac arrest. CASE PRESENTATION A 56-year-old woman who had no medical history was transferred to our hospital for the management of return of spontaneous circulation due to sudden cardiac arrest. Findings of laboratory tests revealed that she had hypothyroidism. On physical examination, she was found to have a puffy face, thin eyebrows, and severe systemic non-pitting edema. Therefore, the patient was clinically diagnosed with myxedema coma, which was the cause of cardiac arrest. She was treated with thyroid hormone and hydrocortisone, resulting in improvement in her general condition, except for the neurological dysfunction. CONCLUSIONS This case suggests that myxedema coma is caused by undiagnosed and untreated hypothyroidism, leading to sudden cardiac arrest. Our findings are useful in the differential diagnosis of hypothyroidism based on characteristic physical examination findings. Clinicians should be aware of the differential diagnosis of myxedema coma based on findings from physical examination and laboratory testing of thyroid function, and the treatment should be started immediately.
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Affiliation(s)
- Asami Yoshinaka
- Department of Anesthesiology, Obihiro Kosei Hospital, West 14, South 10, 080-0024, Obihiro, Hokkaido, Japan
| | - Masayuki Akatsuka
- Department of Anesthesiology, Obihiro Kosei Hospital, West 14, South 10, 080-0024, Obihiro, Hokkaido, Japan.
| | - Shuji Yamamoto
- Department of Anesthesiology, Obihiro Kosei Hospital, West 14, South 10, 080-0024, Obihiro, Hokkaido, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1West 16, Chuo-ku, 060-8543, Sapporo, Hokkaido, Japan
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Abstract
CONTEXT Thyroid storm can present as a multitude of symptoms, the most significant being cardiovascular (CV). It is associated with various manifestations such as cardiac arrhythmia, heart failure, and ischemia. However, the frequencies of events and characteristics associated with patients that experience these events are not known. METHODS Study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015. Total hospitalizations of thyroid storm were identified using appropriate ICD-9 diagnostic codes. The analysis was performed using SAS. OBJECTIVE To better understand the frequency and characteristics CV occurrences associated with thyroid storm, through a retrospective analysis of thyroid storm hospital admissions. DESIGN The study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015. SETTING Total hospitalizations of thyroid storm were identified using International Classification of Diseases (ICD)-9 diagnostic codes. The analysis was performed using Statistical Analysis System (SAS). RESULTS A total of 6380 adult hospitalizations were included in the final analysis, which includes 3895 hospitalizations with CV events (CEs). Most frequently associated CEs were arrhythmia (N = 3770) followed by acute heart failure (N = 555) and ischemic events (N = 150). Inpatient mortality was significantly higher in patients with CEs compared with those without CEs (3.5% vs 0.2%, P < 0.005). The median length of stay was also higher in patients with CEs compared with those without CEs (4 days vs 3 days, P < 0.0005). Atrial fibrillation was the most common arrhythmia type, followed by nonspecified tachycardia. CONCLUSIONS In patients who were hospitalized due to thyroid storm and associated CEs significantly increased in-hospital mortality, length of stay, and cost. Patients with obesity, alcohol abuse, chronic liver disease, and COPD were more likely to have CEs. Patients with CV complications were at higher risk for mortality. In-hospital mortality increased with ischemic events and acute heart failure. Further evaluation is needed to further classify the type of arrhythmias and associated mortality.
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Affiliation(s)
- Zainulabedin Waqar
- Department of Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH 43608, USA
| | - Sindhu Avula
- Department of Cardiology, Mercy St Vincent Medical Center, Toledo, OH 43608, USA
| | - Jay Shah
- Department of Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH 43608, USA
- Department of Cardiology, Mercy St Vincent Medical Center, Toledo, OH 43608, USA
| | - Syed Sohail Ali
- Department of Cardiology, Mercy St Vincent Medical Center, Toledo, OH 43608, USA
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González Calderón IC, López Mejia PA, Saavedra Ortiz MA, González NA, Herrera Acero S. Urgencias endocrinológicas: coma mixedematoso. REPERTORIO DE MEDICINA Y CIRUGÍA 2021. [DOI: 10.31260/repertmedcir.01217372.1003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
En el presente reporte de caso se presenta una urgencia endocrinológica, el coma mixedematoso. Se considera una descompensación del hipotiroidismo y su mortalidad es alta alcanzando hasta 52% en algunas series de casos. Puede desencadenarse por múltiples factores y su presentación clínica es muy variada ya que comprende la afección de diversos sistemas. Se presenta el caso de una paciente femenina de 42 años de edad que consultó al servicio de urgencias del Hospital de San José de Bogotá con sospecha inicial de una de falla cardiaca descompensada, sin embargo, cursó con pobre mejoría ante el manejo instaurado, por lo cual se realizaron estudios de extensión en donde se encontró una función tiroidea deprimida. En este momento se consideró que la paciente padecía un coma mixedematoso, se instauró manejo con dosis altas de levotiroxina oral con lo cual evolucionó de manera favorable y se logró dar de alta a los pocos días.
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17
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Iftikhar MH, Raziq FI, Coll P, Dar AY. Laryngeal myxoedema: a literature review of an uncommon complication of hypothyroidism. BMJ Case Rep 2021; 14:14/4/e241313. [PMID: 33795283 DOI: 10.1136/bcr-2020-241313] [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] [Indexed: 11/03/2022] Open
Abstract
A 59-year-old woman presented to the emergency department with shortness of breath. She had significant oropharyngeal swelling obstructing her upper respiratory tract. A diagnosis of laryngeal myxoedema was made, which was attributed to severe hypothyroidism. She required invasive ventilation and subsequently a tracheostomy. She was treated with levothyroxine and hydrocortisone. She completely recovered with this therapy. In this review, we will discuss similar cases and different therapeutic options. This case also highlights the fact that establishing a diagnosis of laryngeal myxoedema, a condition that can potentially have lethal outcomes and can be challenging.
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Affiliation(s)
| | - Fazal I Raziq
- Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Patrick Coll
- University of Connecticut, Storrs, Connecticut, USA
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Thyroid crisis mimicking clinically mild encephalitis/encephalopathy with a reversible splenial lesion: A pediatric case report. Brain Dev 2021; 43:596-600. [PMID: 33408037 DOI: 10.1016/j.braindev.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/10/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Reversible lesions in the splenium of the corpus callosum (SCC) with viral infections are associated mainly with clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). We report a pediatric patient in thyroid crisis with reversible SCC lesions. CASE DESCRIPTION We diagnosed a 9-year-old girl with thyroid crisis. She had presented with fever, tachycardia, and impaired consciousness. Magnetic resonance imaging revealed hyperintense signals in the splenium and genu of the corpus callosum and a white matter lesion of the left hemisphere in diffusion-weighted imaging. The initial, tentative diagnosis was clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). We initiated intravenous methylprednisolone pulse therapy; thereafter, her level of consciousness rapidly improved. On admission, thyroid function studies revealed elevation of free thyroxine and a low level of thyroid stimulating hormone with thyroid-related autoantibodies. She was begun on thiamazole and was discharged without neurological sequelae. CONCLUSION Thyroid crisis is similar to acute encephalitis or encephalopathy associated with viral infection, especially with MERS, because the clinical and radiological features resemble those of thyroid crisis; therefore, thyroid diseases should be considered as a possible cause of reversible lesions in the splenium of the corpus callosum.
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Erturk MS, Cekic B, Celik M, Ucar H. Microwave ablation of symptomatic benign thyroid nodules: Short- and long-term effects on thyroid function tests, thyroglobulin and thyroid autoantibodies. Clin Endocrinol (Oxf) 2021; 94:677-683. [PMID: 33020965 DOI: 10.1111/cen.14348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Microwave ablation therapy has been attracting great attention due to its advantages such as low complication rate, good cosmetic results and effective nodule shrinking. Although the effect of thermal ablation therapy on the nodule volume reduction rate has been shown several studies, a limited number of papers have been reported for the effects of microwave ablation (MWA) on thyroid function tests. The aim of this study was to investigate the short- and long-term effects of MWA therapy on thyroid function tests (TFTs), thyroglobulin (Tg) and thyroid autoantibodies in euthyroid patients. DESIGN, PATIENTS AND MEASUREMENTS Demographic data of the patients, TFTs, Tg, thyroid autoantibodies and thyroid volume of the nodules were recorded before the procedure and follow-up. Any differences in serum thyroid hormone levels were investigated in pre-, post- and 6-month follow-up periods before and after MWA. RESULTS The difference between all thyroid hormone levels at pre MWA and 24 h after MWA was statistically significant (p < .001). FT3 (4.62) pmol/L and FT4 (10.81) pmol/L median levels increased significantly (p < .001), while thyrotropin (TSH) levels decreased at 24 h after MWA (p < .001). Thyroid antibodies levels were not statistically different at 6-month (p > .05), whereas Tg levels decreased (p < .001) compared to pre MWA. CONCLUSIONS While no significant effect was observed at 6 month, the effect of MWA on thyroid function tests was prominent at 24 h.
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Affiliation(s)
- Mehmet Sercan Erturk
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - Bulent Cekic
- Department of Radiology, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - Mehmet Celik
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Trakya University Medical Faculty, Edirne, Turkey
| | - Havva Ucar
- Department of Clinical Biochemistry, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
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Le TN, Ganim I, Landa E, Patel H, Siraj T. Extreme Weight Loss and Psychosis as Presenting Signs of Thyrotoxicosis. Cureus 2021; 13:e14045. [PMID: 33898131 PMCID: PMC8059775 DOI: 10.7759/cureus.14045] [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: 11/17/2022] Open
Abstract
Thyroid storm is an acute, life-threatening syndrome due to an exacerbation of thyrotoxicosis, which is when you have an excess of thyroid hormone in the body. Thyroid storm can be precipitated by infections, surgery, or untreated thyrotoxicosis. Multisystem involvement is often seen. Typical symptoms include fever and tachycardia, which are rather common, as well as more severe symptoms such as atrial fibrillation, congestive heart failure, hepatic failure, delirium and coma. The Burch-Wartofsky Point Scale is often used for the clinical diagnosis of thyroid storm. Prompt diagnosis and therapy are required to prevent complications and mortality in patients with thyroid storm. Here we present a case of thyroid storm in a patient that presented with psychosis and significant weight loss.
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Affiliation(s)
- Thu Nhi Le
- Internal Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, USA
| | | | - Eric Landa
- Internal Medicine, Unity Health, Searcy, USA
| | - Hemal Patel
- Internal Medicine, Unity Health, Searcy, USA
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Rajendran A, Bhavani N, Nair V, Pavithran PV, Menon VU, Kumar H. Oral Levothyroxine is an Effective Option for Myxedema Coma: A Single-Centre Experience. Eur Thyroid J 2021; 10:52-58. [PMID: 33777819 PMCID: PMC7983610 DOI: 10.1159/000507855] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/12/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Myxedema coma is an endocrine emergency with a very high mortality rate. As per the American Thyroid Association, initial thyroid hormone replacement for myxedema coma should be intravenous levothyroxine (LT4). However, in India, the availability of intravenous LT4 is limited. Often, crushed LT4 tablets are given through the enteral route when parenteral therapy is unavailable. No data or protocol is available for the administration of oral LT4 in myxedema coma. The aim of this study was to assess the effectiveness of oral LT4 in patients diagnosed with myxedema coma and to formulate a protocol for oral LT4 that can be used to guide the treatment of patients when intravenous LT4 is unavailable. METHODS This retrospective observational study included patients diagnosed with myxedema coma between January 2010 and December 2019. The diagnosis of myxedema coma was based on the diagnostic scoring system for myxedema coma proposed by Popoveniuc et al. [Endocr Pract. 2014 Aug;20(8):808-17]. Dosing of oral LT4 was decided as per our institutional protocol. RESULTS Fourteen patients (11 males and 3 females) with a median age of 67.5 years (range 11-82) with myxedema coma were included. All patients had central nervous system manifestations, and sepsis was the most common precipitating factor. The median myxedema score was 72.5 (normal ≤25), and the median length of hospital stay was 12 days (range 3-18). The oral LT4 regimen consisted of a loading dose of 300-500 μg, followed by taper over the next 3-5 days. With this regimen, 13 patients survived, and only 1 patient died. CONCLUSION Oral LT4 is an effective treatment option for myxedema coma when intravenous LT4 is unavailable.
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Affiliation(s)
| | - Nisha Bhavani
- *Nisha Bhavani, Department of Endocrinology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Aims Ponekkara PO, Cochin, Kerala 682041 (India),
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Verma V, Menon AS, Bahadur A, Sikarwar A. Clinical manifestation and images of a patient having cardiovascular involvement in myxoedema coma. Med J Armed Forces India 2021; 77:92-95. [PMID: 33487873 DOI: 10.1016/j.mjafi.2018.12.001] [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] [Received: 03/22/2018] [Accepted: 12/03/2018] [Indexed: 11/17/2022] Open
Abstract
Myxoedema coma is an endocrine emergency characterised by diminished sensorium associated with features of severe hypothyroidism. The disease carries a high mortality of 30%-60 %. The cardiac manifestation of the disease consists of bradycardia, hypotension, pericardial effusion and certain echocardiographic changes such as heart block and features of hypothermia. Here, we report a case of myxoedema coma with characteristic cardiac manifestations. These manifestations revert promptly on starting treatment, and achieving a eumetabolic status as was demonstrated in this patient.
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Affiliation(s)
- Vishesh Verma
- Classified Specialist (Medicine) and Endocrinologist, Command Hospital (Central Command), Lucknow Cantt, India
| | - Anil S Menon
- Commandant, Military Hospital Mhow, Madhya Pradesh, India
| | - Ajay Bahadur
- Senior Advisor (Medicine) and Endocrinologist, Command Hospital (Central Command), Lucknow Cantt, India
| | - Ajeet Sikarwar
- Junior Resident (Medicine), Command Hospital (Central Command), Lucknow Cantt, India
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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: 2] [Impact Index Per Article: 0.7] [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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Gede Utara Hartawan IGA, Agung Senapathi T, Ryalino C, Pradhana A, Irawan A, Imannudin R. Thyroid storm in pregnancy. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_219_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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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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Bridwell RE, Willis GC, Gottlieb M, Koyfman A, Long B. Decompensated hypothyroidism: A review for the emergency clinician. Am J Emerg Med 2020; 39:207-212. [PMID: 33039222 DOI: 10.1016/j.ajem.2020.09.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Decompensated hypothyroidism, formerly known as myxedema coma, is an endocrine emergency that commonly presents with altered mental status, as well as hypothermia and depressed vital signs. The condition is often caused by an inciting event, which may lead to significant delays in the diagnosis and management of this disease. Although the incidence is low, this disease is associated with significant morbidity and mortality. Therefore, it is important for emergency clinicians to be aware of this condition. OBJECTIVE This narrative review evaluates the emergency medicine diagnosis and management of adult patients with decompensated hypothyroidism. DISCUSSION Decompensated hypothyroidism is a severe hypothyroid state associated with multiple organ failure. The diagnosis can be challenging due to similarities with more common diseases and lack of consideration of the diagnosis. Many patients may present with altered sensorium or depressed vital signs. Clinicians should obtain a thyroid stimulating hormone and free thyroxine level when considering the diagnosis. Management involves resuscitation, early steroid supplementation, thyroid hormone replacement, and treatment of the inciting event. CONCLUSIONS Decompensated hypothyroidism should be considered in the evaluation of patients with altered sensorium and depressed vital signs so as to not miss this critical diagnosis.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency, Medicine Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - George C Willis
- Department of Emergency, Medicine University of Maryland School of Medicine, 110 S. Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, United States.
| | - Michael Gottlieb
- Department of Emergency, Medicine Rush University Medical Center, Chicago, IL 60612, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX, 75390, United States
| | - Brit Long
- Department of Emergency, Medicine Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
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Tan AWK, Lim BSP, Hoe JKM, Hoi WH, Leow MKS. Therapeutic plasma exchange for control of thyroid storm. J Clin Apher 2020; 36:189-195. [PMID: 32823374 DOI: 10.1002/jca.21832] [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: 02/27/2020] [Revised: 07/23/2020] [Accepted: 08/06/2020] [Indexed: 12/26/2022]
Abstract
Therapeutic plasma exchange (TPE) for thyroid storm has recently been upgraded to a category II indication after decades though its recommendation level still remains at Grade 2C according to the American Society for Apheresis (ASFA). In the absence of prospective randomized controlled trials due to the rarity of thyroid storm, retrospective data from case series continue to elevate the clinical evidence supporting TPE as a life-saving modality for complicated thyroid storm patients. We report three cases of life-threatening thyroid storm from Graves' disease rescued by TPE via rapid reduction in circulating thyroid hormones. Each patient underwent TPE when it was judged that other thyroid storm treatment options were futile or unsafe. The first patient received 4 cycles of TPE while the second patient received 9 cycles of TPE, and the third patient received 2 cycles of TPE with satisfactory clinical improvement. Plasma FT4 and TSH receptor antibody levels of the first case declined by 41.3% and >50% respectively right after the first round of TPE; plasma FT4 of the second patient dropped by up to 31.6% during the course of TPE; plasma FT4 and TSH receptor antibody of the third patient declined by 66% and 56.2% respectively after the first cycle of TPE. This demonstrates the safety, efficacy, and feasibility of TPE in thyroid storm especially when other therapeutic interventions are contraindicated. TPE operates via the elimination of serum proteins-bound thyroid hormones, thyroid autoantibodies, cytokines, and catecholamines in addition to increasing unsaturated binding sites for thyroid hormones.
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Affiliation(s)
- Alvin W K Tan
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Brenda S P Lim
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Jeremy K M Hoe
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Wai H Hoi
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Melvin K S Leow
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore, Republic of Singapore.,Lee Kong Chian School of Medicine, Singapore, Republic of Singapore.,Duke-NUS Medical School, Singapore, Republic of Singapore.,Yong Loo Lin School of Medicine, Singapore, Republic of Singapore.,Singapore Institute for Clinical Sciences, A*STAR, Singapore, Republic of Singapore
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Maldonado D, Patel U, Tarlin N. A Case of Refractory Myxedema Coma. Cureus 2020; 12:e9737. [PMID: 32944455 PMCID: PMC7489769 DOI: 10.7759/cureus.9737] [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] [Indexed: 11/06/2022] Open
Abstract
We present a case of myxedema coma refractory to traditional treatments. Morbidity and mortality from myxedema coma are frequently due to a missed or delayed diagnosis. It tends to respond very well to intravenous levothyroxine replenishment as long as this treatment is initiated early. We report a case of a 71-year-old man who presented with altered mental status and severe bradycardia who was promptly diagnosed with myxedema coma on laboratory studies sent in the emergency department (thyroid-stimulating hormone 94.74, free T4 0.17, and free T3 0.69). However, while the diagnosis was recognized immediately, and he was treated aggressively with intravenous thyroxine replacement, he strangely remained refractory to treatment for a prolonged period of time. While he did respond to intravenous thyroxine initially, he dramatically decompensated each time he was transitioned to oral therapy. This case brings to question why rarely certain patients fail the transition to oral therapy, and how to treat these patients.
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Abstract
Hypothyroidism is a common condition in which the thyroid gland provides insufficient amounts of thyroid hormone for the needs of peripheral tissues. The most common cause in adults is chronic lymphocytic thyroiditis (Hashimoto thyroiditis), but there are many other causes. Because most of the clinical features of hypothyroidism are nonspecific, the diagnosis requires laboratory testing. Serum thyroid-stimulating hormone (TSH) measurement is the best diagnostic test; an elevated TSH level almost always signals primary hypothyroidism. Serum free thyroxine levels may be below the reference range (overt hypothyroidism) or within the reference range (subclinical hypothyroidism). All patients with overt hypothyroidism should be treated, but those with subclinical hypothyroidism do not always benefit from treatment, especially elderly patients and those with baseline TSH levels below 10 mU/L. Oral L-thyroxine is the treatment of choice because of its well-demonstrated efficacy, safety, and ease of use. Therapy goals are symptom relief and maintenance of serum TSH levels within the reference range. Myxedema coma is a life-threatening form of decompensated hypothyroidism that must be treated with aggressive L-thyroxine replacement and other supportive measures in the inpatient setting.
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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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31
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Divecha CA, Tullu MS, Deshmukh CT, Karande S. Myxedema Coma in a Pediatric Patient with Down Syndrome. J Pediatr Intensive Care 2020; 9:70-73. [PMID: 31984162 PMCID: PMC6978172 DOI: 10.1055/s-0039-1698812] [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: 08/07/2019] [Accepted: 09/12/2019] [Indexed: 12/13/2022] Open
Abstract
Myxedema coma due to severe/long standing hypothyroidism is a known fatal endocrine emergency but is rare in children and unreported in pediatric Down syndrome. It mimics other conditions in the emergency room, making the diagnosis challenging. We present a 10-year-old-male child with global developmental delay and Down syndrome phenotype, admitted for altered sensorium subsequent to a febrile illness. The presence of myxedematous changes on clinical examination, on a background of altered sensorium and hypothermia, led to suspicion of myxedema coma, confirmed by laboratory testing. Due to nonavailability of triiodothyronine (T3), thyroxine (T4) was administered through nasogastric tube after an endocrine consult. Despite initial recovery in terms of improved consciousness, the child ultimately succumbed to refractory shock and terminal ventricular tachycardia. Our case highlights the need to consider myxedema coma as a differential diagnosis for altered mental status in the emergency room and use of screening tools for effective selection of patients.
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Affiliation(s)
- Chhaya A. Divecha
- College of Medicine and Health Sciences, National University of Science and Technology, Sohar, Sultanate of Oman
| | - Milind S. Tullu
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Chandrahas T. Deshmukh
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sunil Karande
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
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32
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Tran M, Vincent L, Ho G, Kelly K, Bouvet M, Meier A. Critical Consideration of Myxedema Coma in the Postoperative Setting: A Case Report. A A Pract 2019; 12:119-121. [PMID: 30169383 DOI: 10.1213/xaa.0000000000000864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Myxedema coma is a rare but highly fatal condition with reported mortality >40%-50%. Early recognition and prompt treatment are critical for survival. Here we describe a case of possible postoperative myxedema coma after subacute neck hematoma evacuation after hemithyroidectomy in a patient on concurrent amiodarone therapy. Symptoms included somnolence, hypothermia, and prolonged QTc with torsades de pointes resistant to magnesium therapy requiring defibrillation and overdrive pacing. Consideration of the possible diagnosis of myxedema coma resulted in prompt therapy and symptom resolution within 48 hours. Thyroid disorders, although rare, should be considered in the postoperative setting.
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Affiliation(s)
- Minh Tran
- From the Department of Anesthesiology
| | | | - Gordon Ho
- Department of Medicine, Division of Cardiology
| | | | | | - Angela Meier
- Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, California
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33
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Ueda K, Kiyota A, Tsuchida M, Okazaki M, Ozaki N. Successful treatment of myxedema coma with a combination of levothyroxine and liothyronine. Endocr J 2019; 66:469-474. [PMID: 30853666 DOI: 10.1507/endocrj.ej18-0469] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Myxedema coma is a rare endocrine emergency resulting from the decompensation of severe hypothyroidism, which is associated with a high mortality rate. It is characterized by the deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation. Early disease diagnosis and advancements in intensive supportive care have reduced the mortality rate. Besides intensive supportive care, appropriate management of the underlying thyroid hormone deficiency is essential. However, as the disease is rare and unrecognized, evidence-based treatment of myxedema has not yet been established in many countries. An 84-year-old Japanese man with a history of Hashimoto's thyroiditis was referred to our hospital. On arrival, conscious disturbance, hypothermia, hypotension, and hypoventilation were observed. He had discontinued thyroid hormone replacement therapy for a year. He was diagnosed with myxedema coma. Immediately, he received intensive supportive care and a combination therapy of 200 μg levothyroxine and 50 μg liothyronine until the fifth hospital day. Subsequently, monotherapy with levothyroxine was continued at a dose of 150 μg daily. The thyroid hormone level reached the normal range a few days later, and cardiovascular disease did not develop during hospitalization. This case demonstrated the efficacy of the combination of levothyroxine and liothyronine in treating myxedema coma.
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Affiliation(s)
- Kazuhiro Ueda
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Atsushi Kiyota
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Mariko Tsuchida
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Mikako Okazaki
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Nobuaki Ozaki
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
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34
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Hakoshima M, Yanai H, Komatsuzaki S, Kawaguchi A, Hamasaki H, Katsuyama H. Streptococcal Infection Can Be the Trigger for Thyroid Storm. J Clin Med Res 2019; 11:383-384. [PMID: 31019634 PMCID: PMC6469890 DOI: 10.14740/jocmr3818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/29/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Mariko Hakoshima
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Hidekatsu Yanai
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Sayako Komatsuzaki
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Akiko Kawaguchi
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | | | - Hisayuki Katsuyama
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
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35
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Mechanical Circulatory Support in Management of Cardiogenic Shock and Myxedema Coma. Case Rep Cardiol 2019; 2019:2595736. [PMID: 30956822 PMCID: PMC6431388 DOI: 10.1155/2019/2595736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/21/2019] [Accepted: 02/11/2019] [Indexed: 12/15/2022] Open
Abstract
The cardiovascular system is a major target of thyroid hormone action and the two systems are closely interlinked. It can be greatly impacted even with subtle alterations in thyroid function. Caution is needed when implementing thyroid hormone replacement in patients with severe hypothyroidism, especially in the setting of ischemic coronary artery disease. If not properly treated, myxedema may ensue. Given the high mortality of myxedema coma, supportive care may not always suffice and patients may require more invasive interventions. We present a challenging case of a patient with overt hypothyroidism with concurrent acute coronary syndrome which subsequently lead to myxedema coma and cardiogenic shock. A transcaval approach for the delivery of an Impella 5.0 (Abiomed Inc., Danvers, MA) was utilized in supporting this patient. To our knowledge, this is the first reported case that describes the use of a mechanical circulatory support in treating myxedema-induced cardiovascular collapse.
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36
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Abstract
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.
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Affiliation(s)
- C Spitzweg
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.
| | - M Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - R Gärtner
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
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37
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Galindo RJ, Hurtado CR, Pasquel FJ, García Tome R, Peng L, Umpierrez GE. National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004-2013. Thyroid 2019; 29:36-43. [PMID: 30382003 PMCID: PMC6916241 DOI: 10.1089/thy.2018.0275] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current evidence on the incidence and outcomes of patients with thyroid storm in the United States is limited to single-center case series. This study determined the national incidence of thyrotoxicosis with and without thyroid storm and clinical outcomes among hospitalized patients during a 10-year period in the United States. METHODS Retrospective longitudinal analysis was conducted of clinical characteristics, mortality, hospital length of stay, and costs from 2004 to 2013. Adults (≥18 years of age) with a primary diagnosis of thyrotoxicosis with and without thyroid storm were included. To determine the incidence, outcomes, and cost of thyrotoxicosis with and without thyroid storm, the study used data from the National Inpatient Sample database, the largest public inpatient database, with a representative sample of all non-federal hospitals in the United States. RESULTS Among 121,384 discharges with thyrotoxicosis during the study period (Mage ± standard error = 48.7 ± 0.11 years; 51.9% Caucasian; 77.3% female), 19,723 (16.2%) were diagnosed with thyroid storm. During the past decade, the incidence of thyroid storm ranged between 0.57 and 0.76 cases/100,000 U.S. persons per year, and 4.8 and 5.6/100,000 hospitalized patients per year. Thyroid storm was associated with significantly higher hospital mortality (1.2-3.6% vs. 0.1-0.4%, p < 0.01) and longer length of stay (4.8-5.6 vs. 2.7-3.4 mean days, p < 0.001) compared to patients with thyrotoxicosis without storm. Inflation-adjusted hospitalization costs progressively increased in patients with thyroid storm from $9942 to $12,660 between 2004 and 2013 (p < 0.01). CONCLUSIONS One of every six discharges for thyrotoxicosis was diagnosed with thyroid storm. Thyroid storm is associated with a 12-fold higher mortality rate compared to thyrotoxicosis without storm. The incidence and mortality of thyroid storm has not substantially changed in the past decade. However, hospitalization costs have significantly increased.
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Affiliation(s)
- Rodolfo J. Galindo
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia
- Address correspondence to: Rodolfo J. Galindo, MD, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr. Dr., Glenn Bld #202, Atlanta, GA 30303
| | - Carolina R. Hurtado
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francisco J. Pasquel
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia
| | - Rodrigo García Tome
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Guillermo E. Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia
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38
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Petersen A, Wang C, Crocoll C, Halkier BA. Biotechnological approaches in glucosinolate production. JOURNAL OF INTEGRATIVE PLANT BIOLOGY 2018; 60:1231-1248. [PMID: 30080309 PMCID: PMC6585788 DOI: 10.1111/jipb.12705] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/31/2018] [Indexed: 05/21/2023]
Abstract
Glucosinolates (GLSs) are sulfur-rich, amino acid-derived defense compounds characteristic of the Brassicales order. In the past, GLSs were mostly known as anti-nutritional factors in fodder, biopesticides in agriculture, and flavors in condiments such as mustard. However, in recent times, GLSs have received increased attention as promoters of human health. This has spurred intensive research towards generating rich sources of health-promoting GLSs. We provide a comprehensive overview of the biotechnological approaches applied to reach this goal. This includes optimization of GLS production and composition in native, GLS-producing plants, including hairy root and cell cultures thereof, as well as synthetic biology approaches in heterologous hosts, such as tobacco and the microbial organisms Escherichia coli and Saccharomyces cerevisiae. The progress using these different approaches is discussed.
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Affiliation(s)
- Annette Petersen
- DynaMo CenterCopenhagen Plant Science CentreDepartment of Plant and Environmental SciencesUniversity of CopenhagenThorvaldsensvej 401871 Frederiksberg CDenmark
| | - Cuiwei Wang
- DynaMo CenterCopenhagen Plant Science CentreDepartment of Plant and Environmental SciencesUniversity of CopenhagenThorvaldsensvej 401871 Frederiksberg CDenmark
| | - Christoph Crocoll
- DynaMo CenterCopenhagen Plant Science CentreDepartment of Plant and Environmental SciencesUniversity of CopenhagenThorvaldsensvej 401871 Frederiksberg CDenmark
| | - Barbara Ann Halkier
- DynaMo CenterCopenhagen Plant Science CentreDepartment of Plant and Environmental SciencesUniversity of CopenhagenThorvaldsensvej 401871 Frederiksberg CDenmark
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39
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Gocho N, Aoki E, Okada C, Hirashima T. Myxedema Coma Following the Administration of Gonadotropin-releasing Hormone Agonist Complicated by Acute Pancreatitis. Intern Med 2018; 57:3117-3122. [PMID: 29877268 PMCID: PMC6262710 DOI: 10.2169/internalmedicine.0639-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/05/2018] [Indexed: 11/29/2022] Open
Abstract
Gonadotropin-releasing hormone (GnRH) agonists have been used for the treatment of various diseases. Although autoimmune thyroid disease has been reported as a rare complication of these agents, the symptoms are almost always transient and non-life-threatening. We herein report a rare case of an 83-year-old man receiving GnRH agonist treatment for prostate cancer who developed myxedema coma complicated by acute pancreatitis. This is the first report of myxedema coma potentially associated with a GnRH agonist. The follow-up of the thyroid function is necessary for patients undergoing treatment with GnRH agonists, especially those known to have or to be susceptible to autoimmune thyroid disease.
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Affiliation(s)
- Naoki Gocho
- Diabetes Center, Ebina General Hospital, Japan
| | - Ema Aoki
- Diabetes Center, Ebina General Hospital, Japan
| | - Chiho Okada
- Diabetes Center, Ebina General Hospital, Japan
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40
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Sefati N, Abbaszadeh HA, Fadaei Fathabady F, Abdollahifar MA, Khoramgah MS, Darabi S, Amini A, Tahmasebinia F, Norouzian M. The Combined Effects of Mesenchymal Stem Cell Conditioned Media and Low-Level Laser on Stereological and Biomechanical Parameter in Hypothyroidism Rat Model. J Lasers Med Sci 2018; 9:243-248. [PMID: 31119018 DOI: 10.15171/jlms.2018.44] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Many studies have shown the positive effect of laser radiation and application of the mesenchymal stem cells (MSCs) and their secretion in stimulating bone regeneration. The aim of this study was determining effects of MSC conditioned media (CM) and low-level laser (LLL) on healing bone defects in the hypothyroid male rat. Methods: We assigned 30 male Wistar rats randomly to 3 groups: control, hypothyroidism, CM+LLL. Four weeks after surgery, the right tibia was removed. Biomechanical examination and histological examinations were performed immediately. Results: Our results showed significant increase in bending stiffness (116.09±18.49), maximum force (65.41±8.16), stress high load (23.30±7.14), energy absorption (34.57±4.10), trabecular bone volume (1.34±0.38) and the number of osteocyte, osteoblast, and osteoclast (12.77±0.54, 6.19±0.80, 1.12±0.16 respectively) in osteotomy site in the LLL+CM group compared to the hypothyroidism group (P<0.05). Conclusion: The results indicated that using the LLL + CM may improve fracture regeneration and it may hasten bone healing in the hypothyroid rat.
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Affiliation(s)
- Niloofar Sefati
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hojjat-Allah Abbaszadeh
- Hearing Disorders Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Fadaei Fathabady
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Amin Abdollahifar
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam-Sadat Khoramgah
- Hearing Disorders Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahram Darabi
- Cellular and Molecular Research Center, Qazvin University of Medical Science, QazviCellular and Molecular Research Center, Qazvin University of Medical Science, Qazvin, Irann, Iran
| | - Abdollah Amini
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Foozhan Tahmasebinia
- Department of Biological Sciences,Institute for Advanced Studies in Basic Sciences (IASBS), Zanjan, Iran
| | - Mohsen Norouzian
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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41
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Abstract
PURPOSE OF REVIEW This article provides an overview of endocrine emergencies with potentially devastating neurologic manifestations that may be fatal if left untreated. Pituitary apoplexy, adrenal crisis, myxedema coma, thyroid storm, acute hypercalcemia and hypocalcemia, hyperglycemic emergencies (diabetic ketoacidosis and hyperglycemic hyperosmolar state), and acute hypoglycemia are discussed, with an emphasis on identifying the signs and symptoms as well as diagnosing and managing these clinical entities. RECENT FINDINGS To identify the optimal management of endocrine emergencies, using formal clinical diagnostic criteria and grading scales such as those recently proposed for pituitary apoplexy will be beneficial in future prospective studies. A 2015 prospective study in patients with adrenal insufficiency found a significant number of adrenal crisis-related deaths despite all study patients receiving standard care and being educated on crisis prevention strategies, highlighting that current prevention strategies and medical management remain suboptimal. SUMMARY Early diagnosis and prompt treatment of endocrine emergencies are essential but remain challenging because of a lack of objective diagnostic tools. The optimal management is also unclear as prospective and randomized studies are lacking. Additional research is needed for these clinical syndromes that can be fatal despite intensive medical intervention.
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Horiuchi K, Nagai A, Wakita M, Ito S, Takamura K, Houzen H. Myasthenic Crisis Complicated with Myxedema, Positive for Both Anti-acetylcholine Receptor and Anti-muscle-specific Tyrosine Kinase Antibodies. Intern Med 2018; 57:265-268. [PMID: 29093409 PMCID: PMC5820048 DOI: 10.2169/internalmedicine.9291-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report the case of myasthenic crisis occurring in a 51-year-old man. He had experienced ptosis, increased body weight with edema, and fatigue with dyspnea. He presented at our emergency department with disturbed consciousness. He was originally diagnosed with myxedema coma, and he required artificial respiration. Because his weakness persisted and he was positive for anti-acetylcholine receptor antibodies and anti-muscle-specific tyrosine kinase antibodies, we diagnosed myasthenic crisis after various examinations. His clinical response to treatment was good and he was discharged in an ambulatory status 3 months after admission. This case demonstrates that myasthenic crisis may occur in association with myxedema.
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Affiliation(s)
| | - Azusa Nagai
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Masahiro Wakita
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Shotaro Ito
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Kei Takamura
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Hideki Houzen
- Department of Neurology, Obihiro Kosei General Hospital, Japan
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Abstract
Graves' disease is the most frequent cause of hyperthyroidism in iodine-sufficient geographical areas and is characterized by the presence in patients' serum of autoantibodies directed against the thyrotropin receptor (TRAb) that cause overproduction and release of thyroid hormones. Clinical presentation results from both hyperthyroidism and underlying autoimmunity. The diagnosis is based on characteristic clinical features and biochemical abnormalities. If serum thyrotropin (TSH) is low, serum free thyroxine (FT4) and free triiodothyronine (FT3) concentrations should be measured to distinguish between subclinical (with normal circulating thyroid hormones) and overt hyperthyroidism (with increased circulating thyroid hormones). Graves' disease is treated with any of three effective and relatively safe initial treatment options: antithyroid drugs (ATDs), radioactive iodine ablation (RAIU), and surgery. Total thyroidectomy is favored in several clinical situations, such as intolerance, ineffectiveness or recurrence after ATD treatment, radioiodine therapy contraindicated, documented or suspected thyroid malignancy, one or more large thyroid nodules, coexisting moderate-to-severe active Graves' orbitopathy, women planning a pregnancy within 6 months. Whenever surgery is selected as treatment, selection of an expert high-volume thyroid surgeons is fundamental and careful preoperative management is essential to optimize surgical outcomes. Pretreatment with ATDs in order to promptly achieve the euthyroid state is recommended to avoid the risk of precipitating thyroid storm during surgery. For the majority of patients, euthyroidism is achieved after few weeks of ATD treatment. Beta-blockers, such as propranolol, are often added effectively to control hyperthyroid symptoms. Saturated solution of potassium iodide (SSKI) or potassium iodine (Lugol's solution), given for a short period prior to surgery, in order to reduce both thyroid hormone release and thyroid gland vascularity, is beneficial to decrease intra-operative blood loss.
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Affiliation(s)
- Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Liu YJ, Qian LX, Liu D, Zhao JF. Ultrasound-guided microwave ablation in the treatment of benign thyroid nodules in 435 patients. Exp Biol Med (Maywood) 2017; 242:1515-1523. [PMID: 28847173 DOI: 10.1177/1535370217727477] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The objective of the present study was to investigate the effectiveness and safety of ultrasound-guided microwave ablation in the treatment of benign thyroid nodules. A total of 474 benign thyroid nodules in 435 patients who underwent ultrasound-guided microwave ablation from September 2012 to August 2015 were included. Nodule volume and thyroid function were measured before treatment and at 1, 3, 6, and 12 months and subsequently after every 6 months. The nodule volume reduction rate and changes of thyroid function were evaluated. The volume of all thyroid nodules significantly decreased after ultrasound-guided microwave ablation. The average volume was 13.07 ± 0.95 ml before treatment, and 1.14 ± 0.26 ml at 12-months follow-up. The mean volume reduction rate was 90% and the final volume reduction rate was 94%. The volume reduction rate of mainly cystic nodules was significantly higher than that of simple solid and mainly solid nodules (all P < 0.05). The pretreatment volume of nodules was positively correlated with the final volume reduction rate at final follow-up ( P = 0.004). No serious complications were observed after treatment. In conclusion, ultrasound-guided microwave ablation is an effective and safe technique for treatment of benign thyroid nodules, and has the potential for clinical applications. Impact statement Ultrasound-guided MWA is an effective and safe technique for the treatment of benign thyroid nodules. It can significantly reduce the nodule volume, improve the patients' clinical symptoms, has less complication, guarantees quick recovery, meets patients' aesthetic needs, and shows less interference on the physiological and psychological aspects of the body. MWA should be a good complement to traditional open surgery and has potentials in clinical applications.
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Affiliation(s)
- Yu-Jiang Liu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin-Xue Qian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Dong Liu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jun-Feng Zhao
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Monteiro AM, Matta-Coelho C, Fernandes V, Marques O. Type 2 Diabetes Decompensation as the Clinical Presentation of Thyroid Storm - Cause or Consequence? EUROPEAN ENDOCRINOLOGY 2017; 13:99-101. [PMID: 29632616 PMCID: PMC5813473 DOI: 10.17925/ee.2017.13.02.99] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/29/2017] [Indexed: 11/24/2022]
Abstract
This case study aims to discuss the unusual forms of hyperthyroidism presentation, the nonspecific symptoms and precipitating events. A 70-year-old male was taken to the emergency department for hyperglycaemia, nausea, vomiting and altered mental status with a week of evolution. He had a past medical history of type 2 diabetes, hypertension and dyslipidemia. He had no history of any recent intercurrent illness or infection. At the emergency room, besides hyperglycaemia, ketonemia and slightly elevated C-reactive protein, the basic laboratory panel workup was normal, as was the head computed tomography. He was admitted for metabolic compensation and to study the altered neurological status. During hospitalisation, despite the good glycemic control, he had no improvements in neurological status. At day four of hospitalisation, thyrotoxicosis with thyroid storm criteria was diagnosed. He started on adequate treatment with complete clinical recovery. The associated morbidity and mortality of thyroid storm requires immediate recognition and treatment. Elderly patients are frequently misdiagnosed or diagnosed later due to fewer and less pronounced signs and symptoms.
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Affiliation(s)
| | | | - Vera Fernandes
- Endocrinology Department, Hospital de Braga, Braga, Portugal
| | - Olinda Marques
- Endocrinology Department, Hospital de Braga, Braga, Portugal
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Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect 2017. [PMID: 28638574 PMCID: PMC5473192 DOI: 10.1080/20009666.2017.1316906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Acute hypokalemic paralysis is a rare cause of acute weakness. Morbidity and mortality associated with unrecognized disease can occur and include respiratory failure and possibly death. Common causes of hypokalemic paralysis include thyrotoxic periodic paralysis (TPP) which is a disorder most frequently seen in Asian males. TPP is characterized by sudden onset of hypokalemia and paralysis that primarily affects the lower extremities. Treatment of TPP includes replacing potassium rapidly, using nonselective beta-blockade and correcting the underlying hyperthyroidism as soon as possible. TPP is curable once euthyroid state is achieved. It is vital for physicians to be able to differentiate TPP from familial hypokalemic periodic paralysis, a more common cause of periodic paralysis in Caucasians and western countries. We describe a 19-year-old Caucasian man who presented with acute onset lower extremity paralysis secondary to acute hypokalemia and was found to have new onset Graves’ disease. Abbreviations: TPP: Thyrotoxic periodic paralysis
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Affiliation(s)
- Marcelle Meseeha
- Department of Internal Medicine, Guthrie Medical Group, PC, Sayre, PA, USA
| | - Behnaz Parsamehr
- Department of Internal Medicine, Guthrie Medical Group, PC, Sayre, PA, USA
| | - Kerri Kissell
- Department of Endocrinology, Diabetes, and Metabolism, Guthrie Medical Group, PC, Sayre, PA, USA
| | - Maximos Attia
- Department of Family Medicine, Guthrie Medical Group, PC, Sayre, PA, USA
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Myxedema Crisis Presenting with Seizures: A Rare Life-Threatening Presentation-A Case Report and Review of the Literature. Case Rep Endocrinol 2017; 2017:4285457. [PMID: 28540093 PMCID: PMC5433413 DOI: 10.1155/2017/4285457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 12/28/2022] Open
Abstract
Myxedema crisis is a life-threatening extreme form of hypothyroidism with a high mortality rate if left untreated. Myxedema crisis is commonly seen in older patients, especially in women, and is associated with signs of hypothyroidism, hypothermia, hyponatraemia, hypercarbia, and hypoxemia. Patients might present with different organ specific symptoms. Seizures are a recognized but rare manifestation of myxedema with a very high mortality rate. Prompt diagnosis and appropriate management may improve the prognosis. Many contributory factors may involve development of seizures in a patient with myxedema. Hyponatraemia is one such cause, which is seen in moderate-severe form in the background of myxedema. We report an elderly male who presented with generalized tonic clonic seizure preceded by memory impairment and drowsiness. He had moderate hyponatraemia and very high thyroid stimulatory hormone levels in association with low free thyroxin levels. Diagnosis of myxedema crisis was made and patient was successfully treated with sodium correction and thyroid hormone replacement.
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Batista AS, Zane LL, Smith LM. Burn-induced Myxedema Crisis. Clin Pract Cases Emerg Med 2017; 1:98-100. [PMID: 29849399 PMCID: PMC5965428 DOI: 10.5811/cpcem.2016.16.31301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 12/10/2016] [Accepted: 12/12/2016] [Indexed: 11/11/2022] Open
Abstract
Myxedema crisis (MC) is a rare but life-threatening illness characterized by multi-system organ impairment from thyroid hormone deficiency that is often brought on by an eliciting event. We present the case of MC with a rapid progression of hypothermia, altered mental status, and respiratory failure that was instigated by a flash burn to the face. The patient’s condition was refractory to rewarming and supportive efforts until thyroid hormone was replaced. This case illustrates the need for a high index of suspicion for patients with a rapid onset of metabolic encephalopathy immediately after an injury or burn.
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Park HS, Kwon SK, Kim YN. Successful treatment of thyroid storm presenting as recurrent cardiac arrest and subsequent multiorgan failure by continuous renal replacement therapy. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM160115. [PMID: 28458893 PMCID: PMC5404465 DOI: 10.1530/edm-16-0115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 02/08/2017] [Indexed: 01/07/2023] Open
Abstract
Summary Thyroid storm is a rare and potentially life-threatening medical emergency. We experienced a case of thyroid storm associated with sepsis caused by pneumonia, which had a catastrophic course including recurrent cardiac arrest and subsequent multiple organ failure (MOF). A 22-year-old female patient with a 10-year history of Graves’ disease was transferred to our emergency department (ED). She had a cardiac arrest at her home and a second cardiac arrest at the ED. Her heart recovered after 20 min of cardiac resuscitation. She was diagnosed with thyroid storm associated with hyperthyroidism complicated by pneumonia and sepsis. Although full conventional medical treatment was given, she had progressive MOF and hemodynamic instability consisting of hyperthermia, tachycardia and hypotension. Because of hepatic and renal failure with refractory hypotension, we reduced the patient’s dose of beta-blocker and antithyroid drug, and she was started on continuous veno-venous renal replacement therapy (CRRT) with intravenous albumin and plasma supplementation. Subsequently, her body temperature and pulse rate began to stabilize within 1 h, and her blood pressure reached 120/60 mmHg after 6 h. We discontinued antithyroid drug 3 days after admission because of aggravated hyperbilirubinemia. The patient exhibited progressive improvement in thyroid function even after cessation of antithyroid drug, and she successfully recovered from thyroid storm and MOF. This is the first case of thyroid storm successfully treated by CRRT in a patient considered unfit for antithyroid drug treatment. Learning points:
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Affiliation(s)
- Han Soo Park
- Department of Internal Medicine, Division of Endocrinology and Metabolism
| | - Su Kyoung Kwon
- Department of Internal Medicine, Division of Endocrinology and Metabolism
| | - Ye Na Kim
- Division of Nephrology, Kosin University College of Medicine, BusanRepublic of Korea
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50
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Abstract
We report on a young adult female presenting with altered mental status and chest pain. Timely review of her electronic medical record revealed a history of panhypopituitarism with poor medication adherence, although this was unknown at the time of her initial evaluation.The patient required hormone replacement and significant fluid resuscitation, followed by definitive treatment with a pericardiocentesis. She was discharged home on hospital day 4, with normalization of her diminished left ventricular ejection fraction at her 1-month follow-up.Although panhypopituitarism and cardiac tamponade are rare diagnoses, we highlight the management of severe hypothyroidism, the importance of early administration of hydrocortisone for panhypopituitarism, and the need for aggressive volume expansion to maintain preload in cardiac tamponade.
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