Hyperthyroidism and Thyroid Storm

Bidirectional Association between Periodontitis and Thyroid Disease: A Scoping Review

Periodontitis is a chronic inflammatory disease of the tissues surrounding and supporting the teeth. Due to the development of chronic inflammation, periodontitis can contribute to the development of several systemic diseases, including thyroid disease. Thyroid pathology includes benign, malignant, and autoimmune conditions leading to hypothyroidism, hyperthyroidism, or euthyroidism. Alterations in thyroid hormones, especially hypothyroidism, can reveal significant oral manifestations, including periodontitis. This scoping review aims to explore the probable causal relationship between periodontitis and thyroid disease, in terms of epidemiology, pathogenesis, and treatment. The search strategy follows the PRISMA-ScR guidelines. PubMed, Scopus, Web of Science, and Cochrane were searched from January 2014 to January 2024, entering the MESH terms "periodontitis" and "thyroid". Of 153 initial records, 20 articles were selected and discussed. There is a high prevalence of periodontitis among patients with thyroid disease, including thyroid cancer. The causes at the basis of this association are genetic factors, the oral microbiome, and proinflammatory cytokines. Periodontal treatment, specifically scaling and root planning, can ameliorate thyroid parameters. Although there are a few randomized controlled studies in the literature, this review lays the foundation for a bidirectional relationship between periodontitis and thyroid disease, the link to which is, once again, systemic inflammation.

Thyroid Storm Precipitated by Diabetic Ketoacidosis and Influenza A: A Case Report and Literature Review

A 46-year-old woman with a history of Graves' disease presented with the chief complaints of appetite loss, weight loss, fatigue, nausea, and sweating. She was diagnosed with diabetic ketoacidosis (DKA), thyroid storm, and influenza A. She was treated with an intravenous insulin drip, intravenous fluid therapy, intravenous hydrocortisone, oral potassium iodine, and oral methimazole. As methimazole-induced neutropenia was suspected, the patient underwent thyroidectomy. It is important to maintain awareness that thyroid storm and DKA can coexist. Furthermore, even patients who have relatively preserved insulin secretion can develop DKA if thyroid storm and infection develop simultaneously.

A critical review and meta-analysis of the association between overt hyperthyroidism and mortality

BACKGROUND

Overt hyperthyroidism has been associated with cardiac arrhythmias, hypercoagulopathy, stroke, and pulmonary embolism, all of which may increase mortality. Some, but not all, studies show an increased mortality in patients with hyperthyroidism. This inconsistency may be due to differences in study design, characteristics of participants, or confounders. In order to test whether hyperthyroidism influences mortality, we performed a critical review and statistical meta-analysis.

METHODS

Based on an electronic PubMed search, using the Medical Subject Heading words such as hyperthyroidism, thyrotoxicosis, and mortality or survival, case-control and cohort studies were selected and reviewed. Using meta-analysis, an overall relative risk (RR) of mortality was calculated.

RESULTS

Eight studies fulfilled the inclusion criteria, six of which showed an increased all-cause mortality; seven studies, including 31,138 patients and 400,000 person years at risk, allowed calculation of mortality in a meta-analysis. Based on this, the RR of overall mortality was 1.21 (95% confidence interval: 1.05-1.38). Analyses including studies considering setting, treatment, and control for co-morbidity did not significantly alter this finding. As the measured heterogeneity (I(2)) ranges from 89.1 to 98.3%, which is much higher than the 50% generally viewed on as a threshold, the statistical heterogeneity is very pronounced in the included studies.

CONCLUSION

In patients diagnosed with hyperthyroidism, mortality is increased by ∼ 20%. Future studies need to address the cause of hyperthyroidism, impact of type of therapy, time dependency, as well as the potential influence of confounding or genetic susceptibility before the question of causality can be answered.

Thyroid storm presenting as intra-abdominal sepsis with multi-organ failure requiring intensive care

Thyroid storm is a rare but life-threatening condition manifesting with several clinical presentations. Atypical thyroid storm should be part of the differential diagnosis in patients with multiple organ dysfunction of unknown aetiology. In this case report, delayed recognition of thyroid storm in a young female who presented with acute abdomen increased the risk of poor outcome. Prompt initiation of anti-thyroid therapy once the diagnosis of thyroid storm was established, combined with adequate vital organ support using a goal-directed therapy protocol in the intensive care unit resulted in a good outcome.

Moyamoya disease associated with Graves disease: special considerations regarding clinical significance and management

OBJECT

In moyamoya disease (MMD), ischemic events are usually precipitated by activities associated with hyperventilation or physical strain. The authors report on four patients with a rare combination of Graves disease-associated thyrotoxicosis and MMD, whose cerebrovascular ischemic events occurred while in a thyrotoxic state. The clinical correlation between MMD and Graves' thyrotoxicosis, and outcome after surgical intervention are described.

METHODS

Four young women, ages 22 to 25 years, presented with profound cerebrovascular ischemic accidents. They had clinical and radiological features consistent with the diagnosis of MMD and were in the active thyrotoxic state of Graves disease. To prevent a future ischemic event, patients underwent superficial temporal artery-middle cerebral artery anastomosis combined with encephalomyosynangiosis or encephaloduroarteriosynangiosis after normalization of their hormonal conditions. All patients have been neurologically stable since revascularization procedures and lead a normal daily life. In patients with MMD, cerebrovascular ischemic events may be precipitated by thyrotoxicosis. One possible pathomechanism of cerebrovascular ischemic aggravation in the thyrotoxic state may be a hemodynamic compromise induced by an excessive increase in the cerebral metabolism and oxygen demand over the compensation of the cerebral blood flow deficit through collateral supply in MMD.

CONCLUSIONS

Surgical revascularization after optimal control of thyrotoxicosis is thought to be an appropriate treatment in patients with MMD concurrent with Graves disease for the prevention of further ischemic events, especially in those with impaired cerebral perfusion and cerebral ischemic symptoms.

Endocrinologic and metabolic complications in the intensive care unit

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

Short-term hazards of low-dose radioiodine ablation therapy in postsurgical thyroid cancer patients

During the last two decades, there has been a trend to use low-dose I-131 ablation therapy in patients with thyroid carcinoma without metastases. However, information regarding the incidence of acute adverse reactions in patients after low-dose radioiodine therapy has not been reported. In this study, the acute radiation effects after low-dose radioiodine ablation therapy in postsurgical differentiated thyroid cancer patients was evaluated. Fifty-six patients with differentiated thyroid cancer were prospectively evaluated. None of these patients had evidence of a distant metastasis. All patients received 40 mCi (1480 MBq) I-131 MIBG orally and were evaluated for symptoms and signs by a physician on the second and seventh days after therapy. Xerostomia and nausea were the most common complaints with the same incidence rate of 5.35%. Gastralgia occurred at a frequency of 3.57%. Pain in the thyroid bed, tenderness over a parotid gland, submandibular glands, change in taste, and vomiting all were found at a frequency of 1.78%. Maximum reactions generally occurred 24-48 hours after therapy. All the symptoms except for xerostomia resolved completely in most patients within a week. In comparison with high-dose ablation therapy published in the literature, the incidence of radiation reactions in low-dose radioiodine therapy was much lower. It was concluded that in patients without lymph node or distant metastases, low-dose I-131 MIBG therapy may be recommended to avoid the high incidence of local complications after high-dose treatment.

Thyroid storm

Despite earlier recognition and treatment of hyperthyroidism, thyroid storm remains a life-threatening, although fortunately rare, medical emergency. Prompt recognition and aggressive treatment employing a multifaceted approach are generally effective at correcting the homeostatic decompensation that is the hallmark of thyroid storm. Research is furthering understanding of the cellular actions of thyroid hormone and may lead to additional, even more effective treatment modalities in the future.

The utility of parenteral glucocorticoids in the emergency department

Exogenous glucocorticoids have wide clinical applicability in emergency medicine. Many uses reported for this class of drugs are supported by only anecdotal evidence of efficacy, while others have been proven or disproven by well-designed studies; this evidence is evaluated here. Because adverse effects are relatively common and may be serious after initiation of steroid therapy in the emergency department, it is important for the emergency physician to review systematically the indications, contraindications, and precautions for the use of parenteral glucocorticoids.