1
|
Seo YJ, Chervu N, Benharash P, Wu JX. National Trends and Outcomes in the Operative Management of Thyroid Storm. Am Surg 2024; 90:2424-2430. [PMID: 38629320 DOI: 10.1177/00031348241248704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
BACKGROUND Thyroid storm is a rare but potentially lethal manifestation of thyrotoxicosis. Guidelines recommend nonoperative management of thyroid storm, but thyroidectomy can be performed if patients fail medical therapy or need immediate resolution of the storm. Outcomes of thyroidectomy for management of thyroid storm remain ill-defined. METHODS Using the National Inpatient Sample from 2016 to 2020, a retrospective analysis was conducted of patients admitted with thyroid storm. Outcomes of interest included operative complications and mortality. Multivariable logistic regression was performed to assess factors associated with receiving thyroidectomy and mortality. RESULTS An estimated 16,175 admissions had a diagnosis of thyroid storm. The incidence of thyroid storm increased from .91 per 100,000 people in 2016 to 1.03 per 100,000 people in 2020, with a concomitant increase in mortality from 2.9% to 5.3% (P < .001). Operative intervention was pursued in 635 (3.9%) cases with a perioperative complication rate of 30%. On multivariable regression, development of acute decompensated heart failure (adjusted odds ratio [AOR] 1.66, 95% Confidence Interval [CI] 1.03-2.68, P = .037) and acute renal failure (AOR 2.10, 95% CI 1.17-3.75, P = .013) increased odds of receiving surgery. The same multivariable model did not show a significant association between thyroidectomy and mortality. DISCUSSION The incidence of thyroid storm and associated mortality increased during the study period. Thyroidectomy is rarely performed during the same admission, with an overall perioperative complication rate of 30% and no effect on mortality. Patients with acute decompensated heart failure and renal failure were more likely to receive an operative intervention.
Collapse
Affiliation(s)
- Young-Ji Seo
- Department of Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Nikhil Chervu
- Department of Surgery, University of California-Los Angeles, Los Angeles, CA, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California - Los Angeles, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California - Los Angeles, Los Angeles, CA, USA
| | - James X Wu
- Department of Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
2
|
Guo Y, Huang D, Sun J, Zhai Z, Xiao H, Hao W, Wang Q, Huang J, Jin M, Lu W. Radioactive Iodine-131 Therapy Reduced the Risk of MACEs and All-Cause Mortality in Elderly with Hyperthyroidism Combined with Type 2 Diabetes. Int J Gen Med 2024; 17:4281-4295. [PMID: 39324146 PMCID: PMC11423839 DOI: 10.2147/ijgm.s484910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 09/18/2024] [Indexed: 09/27/2024] Open
Abstract
Aim This study aimed to assess the efficacy of antithyroid drugs (ATDs) and radioactive iodine-131 (RAI) therapies in reducing the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in patients with hyperthyroidism complicated with type 2 diabetes mellitus (T2DM). Methods Between January 2013 and December 2021, 540 subjects were included in the analysis. All participants were followed up for 9 years, with a median of 54 months (2451 person-years). The subjects were categorized into two groups: the ATDs group (n = 414) and the RAI group (n = 126). According to the free triiodothyronine (FT3) tertiles, the patients receiving RAI were further grouped as follows: low-level (≤ 4.70 pmol/L, n = 42), moderate-level (4.70-12.98 pmol/L, n = 42), and high-level (≥ 12.98 pmol/L, n = 42). The efficacy of ATDs and RAI therapies in reducing the risk of MACEs and all-cause mortality was assessed. Results Of the 540 participants, 163 experienced MACEs (30.19%), 25 (15.34%) of whom died. Multivariate Cox regression analyses revealed that RAI was associated with a 38.5% lower risk of MACEs (P = 0.016) and a 77.1% lower risk of all-cause mortality (P = 0.046). Stratified analyses indicated that RAI had a protective effect on MACEs in patients aged ≥ 60 years (P = 0.001, P for interaction = 0.031) and patients with a duration of diabetes mellitus ≥ 6 years (P = 0.013, P for interaction = 0.002). Kaplan‒Meier analysis revealed a lower cumulative incidence of MACEs and all-cause mortality in the RAI group (log-rank, all P < 0.05). Moreover, the ROC curve suggested an optimal FT3 cut-off value of 5.4 pmol/mL for MACE (P < 0.001). Conclusion Our findings suggested that RAI therapy effectively reduced the risk of MACEs and all-cause mortality in elderly patients with hyperthyroidism combined with T2DM.
Collapse
Affiliation(s)
- Yanli Guo
- Department of Endocrinology, Heji Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, 046011, People's Republic of China
| | - Dinggui Huang
- Project Fund Supervision Center, Health Commission of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Jingxia Sun
- Department of Endocrinology and Metabolism, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Zhenwei Zhai
- Department of Endocrinology and Metabolism, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Hewei Xiao
- Scientific Research Cooperation Department, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Weiguang Hao
- Department of Endocrinology, Tongde Hospital, Yuncheng, Shanxi, 044000, People's Republic of China
| | - Qiu Wang
- Department of Endocrinology and Metabolism, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Jianhao Huang
- Department of Endocrinology and Metabolism, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Miaomiao Jin
- Department of Endocrinology, Heji Affiliated Hospital of Changzhi Medical College, Changzhi, Shanxi, 046011, People's Republic of China
| | - Wensheng Lu
- Department of Endocrinology and Metabolism, Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| |
Collapse
|
3
|
Kurimoto C, Furukawa Y, Akamizu T, Doi A, Takeshima K, Morita S, Iwakura H, Ariyasu H, Furuta H, Nishi M, Matsuoka TA. Generation of a mouse model of thyroid storm and preliminary investigation of the therapeutic effects of ghrelin. BMC Endocr Disord 2024; 24:150. [PMID: 39135012 PMCID: PMC11318345 DOI: 10.1186/s12902-024-01680-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 08/06/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Thyroid storm (TS), a life-threatening condition that can damage multiple organs, has limited therapeutic options. Hypercytokinemia is a suggested background, but the pathological condition is unclear and there are no appropriate animal models. We aimed to develop a TS mouse model by administration of triiodothyronine and lipopolysaccharide, and then to examine the effects of ghrelin on this model. METHODS We evaluated the use of serum IL-6 levels as a representative marker of hypercytokinemia in patients with TS. To establish the mouse model, preliminary experiments were conducted to determine the non-lethal doses of triiodothyronine and lipopolysaccharide when administered individually. As a TS model, C57BL/6 mice were administered with triiodothyronine 1.0 mg/kg (subcutaneously, once daily for seven consecutive days) and lipopolysaccharide 0.5 mg/kg (intraperitoneally, on day 7) to develop a lethal model with approximately 30% survival on day 8. We assessed the survival ratio, mouse sepsis scores and blood biomarkers (IL-6, metanephrine, alanine aminotransferase) and evaluated the effects of ghrelin 300 µg/kg on these parameters in TS model. RESULTS Serum IL-6 was increased in patients with TS compared with those with Graves' disease as the diseased control (18.2 vs. 2.85 pg/mL, P < .05, n = 4 each). The dosage for the murine TS model was triiodothyronine 1.0 mg/kg and lipopolysaccharide 0.5 mg/kg. The TS model group had increased mouse sepsis score, serum IL-6, metanephrine and alanine aminotransferase. In this model, the ghrelin improved the survival rate to 66.7% (P < .01, vs. 0% [saline-treated group]) as well as the mouse sepsis score, and it decreased the serum IL-6 and metanephrine. CONCLUSION We established an animal model of TS that exhibits pathophysiological states similar to human TS with induction of serum IL-6 and other biomarkers by administration of T3 and LPS. The results suggest the potential effectiveness of ghrelin for TS in humans.
Collapse
Affiliation(s)
- Chiaki Kurimoto
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasushi Furukawa
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Akamizu
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan.
- Department of Internal Medicine, Kuma Hospital, Hyogo, Japan.
| | - Asako Doi
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken Takeshima
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shuhei Morita
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroshi Iwakura
- Department of Pharmacotherapeutics, Wakayama Medical University, Wakayama, Japan
| | - Hiroyuki Ariyasu
- Department of Diabetes and Endocrinology, Shizuoka General Hospital, Shizuoka, Japan
| | - Hiroto Furuta
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Taka-Aki Matsuoka
- First Department of Medicine, Wakayama Medical University, Wakayama, Japan
| |
Collapse
|
4
|
Guzzetti L, Inversini D, Bacuzzi A. Anaesthesia for thyroid and parathyroid surgery. BJA Educ 2024; 24:270-276. [PMID: 39099753 PMCID: PMC11293567 DOI: 10.1016/j.bjae.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 03/08/2024] [Accepted: 04/23/2024] [Indexed: 08/06/2024] Open
Affiliation(s)
- L. Guzzetti
- University Hospital Varese ASST Settelaghi, Varese, Italy
| | - D. Inversini
- University Hospital Varese ASST Settelaghi, Varese, Italy
| | - A. Bacuzzi
- University Hospital Varese ASST Settelaghi, Varese, Italy
| |
Collapse
|
5
|
Barnett MJL, Casipit C, Sathi SRT, Rodriguez ADCR. Rectal thionamide administration in the setting of thyroid storm: a case report and review of the literature. Endocrinol Diabetes Metab Case Rep 2024; 2024:24-0067. [PMID: 39230042 PMCID: PMC11378121 DOI: 10.1530/edm-24-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 07/30/2024] [Indexed: 09/05/2024] Open
Abstract
Summary Thyroid storm is a clinical diagnosis characterized by life-threatening multisystemic organ involvement in the setting of uncontrolled hyperthyroidism. Current estimates suggest a mortality rate of up to 30%. Treatment often consists of the administration of thionamide medications, iodine solution(s), corticosteroids, and beta-blockers; in extreme circumstances, both plasmapheresis and thyroidectomy are subsequent therapeutic options. Thionamides are typically administered orally, with the intent of preventing further thyroid hormone synthesis; however, in the literature, there are instances whereby oral access cannot be obtained, and alternative routes of administration are required. We present a case of a patient who presented with a thyroid storm due to lack of adherence to methimazole. During admission, he was found to have significant abdominal pain and ultimately a duodenal perforation requiring strict nil-per-os (NPO) status, due to which he was unable to receive oral thionamides. Due to the lack of availability of intravenous formulations of thionamides in the United States, this patient was treated with an enema compound of propylthiouracil for a total of five per rectum (PR) doses. He would later develop hepatocellular injury, requiring discontinuation and eventual transition to oral methimazole. The literature pertaining to alternative-route thionamide administration is scant, and therefore this case report and literature review is written to provide an up-to-date review and further educate all levels of clinicians about this infrequent (but emergent) situation. Learning points Thyroid storm is a clinical diagnosis for which urgent recognition is required to prevent untoward mortality. Treatment for thyroid storm requires prompt administration of thionamides, iodine, corticosteroids, and beta-blockers. In extreme circumstances, treatment considerations include plasmapheresis and thyroidectomy. Infrequently, patients with a thyroid storm may not be able to tolerate oral medications, for which alternative routes of access are required. Currently, available alternatives include intravenous methimazole (in Europe and Japan), as well as both enema and suppository preparations of propylthiouracil and methimazole.
Collapse
Affiliation(s)
| | - Carlo Casipit
- Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|
6
|
Matsuo Y, Jo T, Watanabe H, Matsui H, Fushimi K, Yasunaga H. Clinical Efficacy of Beta-1 Selective Beta-Blockers Versus Propranolol in Patients With Thyroid Storm: A Retrospective Cohort Study. Crit Care Med 2024; 52:1077-1086. [PMID: 38551468 DOI: 10.1097/ccm.0000000000006285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVES Thyroid storm is the most severe manifestation of thyrotoxicosis. Beta-blockers are among the standard treatment regimens for this condition, with propranolol being the historically preferred option. However, 2016 guidelines issued by the Japan Thyroid Association and the Japan Endocrine Society recommend the use of beta-1 selective beta-blockers over nonselective beta-blockers, such as propranolol. Nevertheless, evidence supporting this recommendation is limited. Herein, we aimed to investigate the in-hospital mortality of patients with thyroid storms based on the choice of beta-blockers. DESIGN Retrospective cohort study. SETTING The Diagnosis Procedure Combination database, a national inpatient database in Japan. PATIENTS Patients hospitalized with thyroid storm between April 2010 and March 2022. INTERVENTIONS Propensity-score overlap weighting was performed to compare in-hospital mortality between patients who received beta-1 selective beta-blockers and those who received propranolol. Subgroup analysis was also conducted, considering the presence or absence of acute heart failure. MEASUREMENTS AND MAIN RESULTS Among the 2462 eligible patients, 1452 received beta-1 selective beta-blockers and 1010 received propranolol. The crude in-hospital mortality rates were 9.3% for the beta-1 selective beta-blocker group and 6.2% for the propranolol group. After adjusting for baseline variables, the use of beta-1 selective beta-blockers was not associated with lower in-hospital mortality (6.3% vs. 7.4%; odds ratio, 0.85; 95% CI, 0.57-1.26). Furthermore, no significant difference in in-hospital mortality was observed in patients with acute heart failure. CONCLUSIONS In patients with thyroid storm, the choice between beta-1 selective beta-blockers and propranolol did not affect in-hospital mortality, regardless of the presence of acute heart failure. Therefore, both beta-1 selective beta-blockers and propranolol can be regarded as viable treatment options for beta-blocker therapy in cases of thyroid storm, contingent upon the clinical context.
Collapse
Affiliation(s)
- Yuichiro Matsuo
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Taisuke Jo
- Department of Health Services Research, University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Hideaki Watanabe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
| |
Collapse
|
7
|
Mengesha S, Tadesse A, Worku BM, Alamrew K, Yesuf T, Gedamu Y. Control rate of hyperthyroidism and its associated factors after prolonged use of anti-thyroid drugs in a hospital setting, Northwest Ethiopia. Medicine (Baltimore) 2024; 103:e38201. [PMID: 38847659 PMCID: PMC11155532 DOI: 10.1097/md.0000000000038201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/19/2024] [Indexed: 06/10/2024] Open
Abstract
Hyperthyroidism is increased synthesis and secretion of thyroid hormones by the thyroid gland resulting in thyrotoxicosis. The modality of therapy for hyperthyroidism includes anti-thyroid drugs, radioiodine and surgery. Anti-thyroid drugs are the only available therapy for hyperthyroid patients in developing world as radioiodine is inaccessible and surgical set up does not exist as required. The aim of this study was to determine the magnitude and predictors of uncontrolled hyperthyroidism among hyperthyroid patients after prolonged anti-thyroid drug use. An institutional-based cross sectional study was conducted at the University of Gondar hospital, Northwest Ethiopia, between April 1, 2022 and October 31, 2022. A consecutive sampling method was used to recruit 317 study subjects. Data were collected through a pre-designed questionnaire. Patients were interviewed to obtain socio-demographic data and relevant medical information. Laboratory analyses were done based on the follow up protocol. Data were entered into EPI Info version 4.6.0.0 (EPI Info, Atlanta) and analyzed in STATA version 14 (Stata Corp LP, Texas, USA). Binary logistic regression model was used to identify variables associated with uncontrolled hyperthyroidism among hyperthyroid patients. P value < .05 was used to declare significant association. A total of 317 patients with hyperthyroidism were included in the study. The median age of the study subjects was 45 years (IQR 36-55 years). Most (95%) of the study participants were females. Toxic multi-nodular goiter was the most common cause of hyperthyroidism (92%), followed by toxic adenoma (5%) and Graves' disease (2%). On multivariate binary logistic regression, large goiter size (AOR: 3.163, 95% CI [1.333-7.506]), severe disease (AOR: 2.275, 95% CI [1.060-4.880]), infrequent iodinated salt intake (AOR: 3.668, 95% CI [1.245-10.802]), and poor adherence to anti-thyroid drug (AOR:15.724, 95% CI [5.542-44.610]) were statistically significant with uncontrolled hyperthyroidism at 12 months of anti-thyroid drug intake. A quarter of patients with hyperthyroidism didn't achieve euthyroid state after 12 months of anti-thyroid drug use. The identified predictors for non-euthyroid state were large goiter size, severe disease, infrequent iodinated salt intake, and poor adherence to anti-thyroid drug.
Collapse
Affiliation(s)
- Seyoum Mengesha
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abilo Tadesse
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biruk Mulat Worku
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kifle Alamrew
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tesfaye Yesuf
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yonas Gedamu
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
8
|
Shi R, Meng W, Yin J, Xue W, Deng Y. Reversible acute heart failure induced by thyrotoxic cardiomyopathy: A case report. Medicine (Baltimore) 2024; 103:e38305. [PMID: 38788008 PMCID: PMC11124643 DOI: 10.1097/md.0000000000038305] [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] [Received: 01/28/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
RATIONALE Thyrotoxic cardiomyopathy is a rare but severe complication of thyrotoxicosis, leading to episodes of acute heart failure. This case report highlights a rare presentation of thyrotoxic cardiomyopathy with low-output heart failure, emphasizing the importance of early diagnosis and comprehensive management. The report aims to increase awareness among clinicians about the potential reversibility of this condition and the effective strategies for managing such complex cases. PATIENT CONCERNS This patient presented with dyspnea and chest constriction, without any antecedent predisposing factors. Subsequently, the patient abruptly manifested symptoms indicative of acute heart failure during outpatient consultation. Electrocardiography revealed rapid atrial fibrillation with type A preexcitation syndrome, whereas cardiac ultrasonography demonstrated global cardiac enlargement with a diminished ejection fraction (EF). DIAGNOSES After a comprehensive evaluation, the patient was diagnosed with thyrotoxic cardiomyopathy, acute heart failure, and atrial fibrillation with preexcitation syndrome. INTERVENTIONS Immediate interventions comprised diuretic administration, oxygen therapy, and antiarrhythmic agents, addressing acute heart failure concomitant with preexcitation syndrome. Following a fortnight of comprehensive therapeutic measures, the patient was discharged with a prescription for oral medications, notably methimazole. OUTCOMES Following the intervention, the patient showed significant improvement with the resolution of heart failure symptoms and dyspnea, restoration of sinus rhythm, improved left ventricular ejection fraction (LVEF improved from 36% to 45%), and normalization of thyroid function. These outcomes underscore the efficacy of the intervention strategy and offer a hopeful prognosis for similar cases. LESSONS Thyrotoxicosis may cause cardiomyopathy in patients with heart failure that manifests as dilated cardiac chambers. Clinicians should carefully screen patients for this reversible condition. Diagnosis requires a comprehensive assessment of various tests, and the therapeutic goal is to restore normal thyroid function.
Collapse
Affiliation(s)
- Rui Shi
- Department of Cardiovascular Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Wenyi Meng
- Department of Emergency Medicine, Affiliated Hospital, Changchun University of Chinese Medicine, Changchun, China
| | - Jinzhu Yin
- Department of Cardiovascular Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Wen Xue
- Department of Cardiovascular Medicine, Changchun University of Chinese Medicine, Changchun, China
| | - Yue Deng
- Department of Cardiovascular Medicine, Changchun University of Chinese Medicine, Changchun, China
- TCM Cardiovascular Clinical Medicine Research Center of Jilin Province, Changchun, China
| |
Collapse
|
9
|
Medhioub M, Khsiba A, Mahmoudi M, Mohamed AB, Yakoubi M, Haouet E, Hamzaoui L. Thyroid storm-induced acute liver dysfunction and portal hypertension in a patient with Graves' disease: a case report. Future Sci OA 2024; 10:FSO929. [PMID: 38817376 PMCID: PMC11137784 DOI: 10.2144/fsoa-2023-0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/27/2023] [Indexed: 06/01/2024] Open
Abstract
Thyroid storm is a life-threatening condition associated with multiorgan dysfunction and decompensation. We report the case of a 41-year-old woman having Graves' disease presented with thyroid storm complicated with liver dysfunction and portal hypertension in the absence of congestive heart failure or known liver disease. After successful therapeutic management, all biological, clinical and morphological abnormalities regressed.
Collapse
Affiliation(s)
- Mouna Medhioub
- Université Tunis El Manar, faculté de médecine de Tunis, 1007, Tunis, Tunisia
- Gastroenterology department, Mohamed Taher Maamouri Hospital, 8000, Mrezgua, Nabeul, Tunisia
| | - Amal Khsiba
- Université Tunis El Manar, faculté de médecine de Tunis, 1007, Tunis, Tunisia
- Gastroenterology department, Mohamed Taher Maamouri Hospital, 8000, Mrezgua, Nabeul, Tunisia
| | - Moufida Mahmoudi
- Université Tunis El Manar, faculté de médecine de Tunis, 1007, Tunis, Tunisia
- Gastroenterology department, Mohamed Taher Maamouri Hospital, 8000, Mrezgua, Nabeul, Tunisia
| | - Asma Ben Mohamed
- Université Tunis El Manar, faculté de médecine de Tunis, 1007, Tunis, Tunisia
- Gastroenterology department, Mohamed Taher Maamouri Hospital, 8000, Mrezgua, Nabeul, Tunisia
| | - Manel Yakoubi
- Université Tunis El Manar, faculté de médecine de Tunis, 1007, Tunis, Tunisia
- Gastroenterology department, Mohamed Taher Maamouri Hospital, 8000, Mrezgua, Nabeul, Tunisia
| | - Emna Haouet
- Endocrinology department B, Nationale Institute of Nutrition, 1007, Tunis, Tunisia
| | - Lamine Hamzaoui
- Université Tunis El Manar, faculté de médecine de Tunis, 1007, Tunis, Tunisia
- Gastroenterology department, Mohamed Taher Maamouri Hospital, 8000, Mrezgua, Nabeul, Tunisia
| |
Collapse
|
10
|
Lath D, Nandipati VS, Jebasingh F, Cherian KE, Kapoor N, Asha HS, Paul TV, Thomas N. A Lower Prevalence of Central Nervous System and Higher Prevalence of Cardiac Symptoms Characterises Indian Patients with Thyrotoxic Storm: A Retrospective Analysis. Indian J Endocrinol Metab 2024; 28:302-307. [PMID: 39086568 PMCID: PMC11288511 DOI: 10.4103/ijem.ijem_355_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/12/2024] [Accepted: 03/30/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Thyroid storm is an uncommon but life-threatening presentation of thyrotoxicosis with a mortality rate of 10%. Our objective was to study the demographics, clinical and biochemical characteristics, and outcomes of inpatients diagnosed with thyroid storm in the Indian context. Methods This retrospective study was conducted by analysing the institutional electronic medical records (EMR) of all patients admitted with thyroid storm from 2004 to 2020 with a Burch-Wartofsky score (BWS) of ≥45. Results Thirty-five patients with a BWS ≥45 were included, of whom 71.4% were women, with a mean age of 44.9 ± 10.2 years. 43% did not have any prior history of thyrotoxicosis. Graves' disease was the most common underlying aetiology (71.4%), followed by toxic multinodular goitre (14.3%). Cardiovascular (94.3%) and gastrointestinal-hepatic dysfunction (88.6%) were the most common clinical manifestations. Features of Central nervous system (CNS) dysfunction were seen in only 42.3% of patients diagnosed with a thyroid storm. The Japanese Thyroid Association (JTA) criteria diagnosed only 26 patients (74.3%) with "definite" thyroid storm. The mortality rate was 8.6%, and all three patients expired within 48 hours of admission. Conclusion Nearly one in every two patients with thyroid storm had previously undiagnosed thyrotoxicosis. Toxic multinodular goitre is a notable aetiology in Indians. Features of CNS dysfunction, considered relatively specific for thyroid storm, were less prominent in our series. The JTA criteria might alter the classification of some patients diagnosed with a thyroid storm, when compared to the BWS score due to fewer CNS features among Indian patients.
Collapse
Affiliation(s)
- Devraj Lath
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Venkata S. Nandipati
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Felix Jebasingh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Kripa E. Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Hesarghatta S. Asha
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Thomas V. Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
11
|
Rácz K, Simon G, Kurucz A, Harsányi GT, Török M, Herczeg LT, Gergely PA. Case Report: A Sudden Thyroid-Related Death of a 15-Year-Old Girl. Diagnostics (Basel) 2024; 14:905. [PMID: 38732319 PMCID: PMC11083324 DOI: 10.3390/diagnostics14090905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
A 15-year-old young girl was found dead at home. There were no indications of any intervention or the application of force. On the previous day, she was admitted to hospital because of palpitations, fatigue, a headache, and a swollen neck. During a physical examination, a swollen thyroid gland and tachycardia were found. In the family history, her mother had thyroid disease. According to the laboratory values, she had elevated thyroid hormone levels. After administration of beta-blockers, the patient was discharged and died at home during the night. The parents denounced the hospital for medical malpractice; therefore, a Forensic Autopsy was performed. Based on the available clinical data, the autopsy, histological and toxicological results, the cause of death was stated as multiorgan failure due to disseminated intravascular coagulation (DIC) caused by the autoimmune Graves disease. The forensic assessment of the case does not reveal medical malpractice. Post-mortem diagnoses of thyroid disorders in cases of sudden death can be challenging. However, as the reported case illustrates, the diagnosis could be established after a detailed evaluation of antemortem clinical data, autopsy results, histology, and a toxicological examination.
Collapse
Affiliation(s)
- Kálmán Rácz
- Clinical Center, Department of Forensic Medicine, University of Debrecen, 4032 Debrecen, Hungary; (K.R.); (L.T.H.); (P.A.G.)
| | - Gábor Simon
- Medical School, Department of Forensic Medicine, University of Pécs, 7624 Pécs, Hungary
| | - Andrea Kurucz
- Clinical Center, Department of Cardiology and Cardiac Surgery, University of Debrecen, 4032 Debrecen, Hungary;
| | - Gergő Tamás Harsányi
- Pathology Department, Szabolcs-Szatmár-Bereg County Teaching Hospital, 4400 Nyíregyháza, Hungary;
| | - Miklós Török
- Clinical Center, Department of Pathology, Kenézy Gyula Campus, University of Debrecen, 4032 Debrecen, Hungary;
| | - László Tamás Herczeg
- Clinical Center, Department of Forensic Medicine, University of Debrecen, 4032 Debrecen, Hungary; (K.R.); (L.T.H.); (P.A.G.)
| | - Péter Attila Gergely
- Clinical Center, Department of Forensic Medicine, University of Debrecen, 4032 Debrecen, Hungary; (K.R.); (L.T.H.); (P.A.G.)
| |
Collapse
|
12
|
Miao B, Wu J, Jiao W, Yanxin L, Da Y, Dong W, Gao B. Correlation between SUA and prognosis in CHF patients after revascularization. J Med Biochem 2024; 43:193-199. [PMID: 38699691 PMCID: PMC11062339 DOI: 10.5937/jomb0-45322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/11/2023] [Indexed: 05/05/2024] Open
Abstract
Background To explore the correlation between serum uric acid (SUA) and prognosis in patients with chronic heart failure (CHF) after revascularization. Methods A total of 126 patients with CHF undergoing revascularization [coronary artery intervention (PCI) or coronary artery bypass grafting (CABG)] in the hospital were enrolled as CHF group between December 2021 and October 2022, while 126 healthy controls during the same period were enrolled as healthy control group. The levels of SUA, inflammatory factors and cardiac function in the two groups were detected. The correlation between SUA level and inflammatory factors, cardiac function levels was analyzed. All patients in CHF group were followed up for 6 months to observe prognosis. The differences in the above indexes among patients with different prognosis were compared. The risk factors of prognosis were analyzed by multivariate Logistic regression analysis, and their predictive value for prognosis was evaluated by ROC curves analysis.
Collapse
Affiliation(s)
- Bo Miao
- Xingtai Third Hospital, Cardiovascular Intensive Care Unit, Xingtai, China
| | - Jing Wu
- Xingtai Third Hospital, Department 2 of Cardiology, Xingtai, China
| | - Wang Jiao
- Xingtai Third Hospital, Cardiovascular Intensive Care Unit, Xingtai, China
| | - Li Yanxin
- Xingtai Third Hospital, Department 1 of Cardiology, Xingtai, China
| | - Yingxiao Da
- Xingtai Third Hospital, Department 2 of Cardiology, Xingtai, China
| | - Wang Dong
- The Second Hospital of Hebei Medical University, Department of Cardiology, Shijiazhuang, China
| | - Bei Gao
- Xingtai Central Blood Station, Xingtai, China
| |
Collapse
|
13
|
Tu F, Lin Y, Chen J, Zhou L, Lin L, Liu Q, Wu W. Case report and literature review: A thyroid storm patient with severe acute hepatic failure treated by therapeutic plasma exchange and a double plasma molecular absorption system. Heliyon 2024; 10:e28867. [PMID: 38601545 PMCID: PMC11004571 DOI: 10.1016/j.heliyon.2024.e28867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
Thyroid storm (TS) leading to acute liver failure is rare but fatal in clinical practice and hepatic failure can remarkably limit medication options for TS. We successfully cured a patient with TS complicated with acute hepatic failure using therapeutic plasma exchange (TPE) and a double plasma molecular absorption system (DPMAS) and summarized the case characteristics of 10 similar critical patients reported worldwide. We recommend that patients with TS complicated with liver failure disuse propylthiouracil or methimazole. TPE should be utilized to rapidly decrease thyroid hormone levels, and DPMAS should be considered for supportive treatment in the presence of hepatic encephalopathy or dramatic bilirubin elevations.
Collapse
Affiliation(s)
- Fuquan Tu
- Department of Emergency Medicine, Fujian Medical University Union Hospital, Fujian, China
- Intensive Care Unit, Fujian Medical University Union Hospital Qishan Campus, Fujian, China
| | - Yiqin Lin
- Intensive Care Unit, Fujian Medical University Union Hospital Qishan Campus, Fujian, China
| | - Junnian Chen
- Intensive Care Unit, Fujian Medical University Union Hospital Qishan Campus, Fujian, China
| | - Lili Zhou
- Intensive Care Unit, Fujian Medical University Union Hospital Qishan Campus, Fujian, China
| | - Liyong Lin
- Department of Emergency Medicine, Fujian Medical University Union Hospital, Fujian, China
| | - Qin Liu
- Department of Emergency Medicine, Fujian Medical University Union Hospital, Fujian, China
| | - Wenwei Wu
- Department of Emergency Medicine, Fujian Medical University Union Hospital, Fujian, China
- Intensive Care Unit, Fujian Medical University Union Hospital Qishan Campus, Fujian, China
| |
Collapse
|
14
|
Hayashi M, Hayashi K, Miyoshi M, Kobayashi Y, Sato M. Hashimoto Encephalopathy and Thyroid Storm by Diabetic Ketoacidosis and Acute Pancreatitis: A Case Report. Cureus 2024; 16:e53659. [PMID: 38455797 PMCID: PMC10917642 DOI: 10.7759/cureus.53659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Hashimoto encephalopathy (HE) is a rare condition related to autoimmune origin characterized by high titers of antithyroid antibodies. Steroids are effective for treatment of HE, suggesting the autoimmunity as an underlying mechanism. In addition, anti-NH2-terminal of α-enolase antibodies (anti-NAE antibodies) is useful for diagnosis of HE. This report describes a 69-year-old woman developing both HE and thyroid storm (TS), following diabetic ketoacidosis (DKA) and acute pancreatitis. She had a history of Basedow's disease and uncontrolled type 2 diabetes mellitus, and her serum hemoglobin A1c was 10%. She complained of nausea and visited our hospital. She was diagnosed with DKA and acute pancreatitis. After admission, she went into cardiopulmonary arrest and she was diagnosed with TS after resuscitation. In addition, blood test collected during acute phase of TS revealed positive for not only anti-thyroid peroxidase (TPO) antibodies, thyroid stimulating hormone receptor antibodies and thyroid stimulating antibodies, but also anti-NAE antibodies. She was treated with intravenous steroids, potassium iodide and thiamazole under respirator and recovered sufficiently to do daily activities of life. We should keep in mind that there might be cases of HE in cases of TS presenting with central nervous system symptoms.
Collapse
Affiliation(s)
- Maho Hayashi
- Internal Medicine, Fukui General Hospital, Fukui, JPN
| | - Koji Hayashi
- Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| | | | | | - Mamiko Sato
- Rehabilitation Medicine, Fukui General Hospital, Fukui, JPN
| |
Collapse
|
15
|
Vadini V, Vasistha P, Shalit A, Maraka S. Thyroid storm in pregnancy: a review. Thyroid Res 2024; 17:2. [PMID: 38229163 DOI: 10.1186/s13044-024-00190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Thyroid storm is a state of circulating thyroid hormone excess leading to multiorgan dysfunction and systemic decompensation. It typically occurs in the setting of poorly controlled hyperthyroidism and a precipitating illness or event. Management of thyroid storm in pregnancy poses unique diagnostic and therapeutic challenges. MAIN BODY Thyroid storm is a clinical diagnosis characterized by hyperpyrexia, tachyarrhythmias, congestive heart failure, gastrointestinal and neuropsychiatric disturbances. However, diagnostic scoring systems have not been validated in pregnancy. Treatment involves specialist consultation, supportive care, and pharmacological options such as anti-thyroid medications, beta blockers, iodine solutions, glucocorticoids, and cholestyramine. These must be adapted and modified in pregnancy to prevent fetal and maternal complications. CONCLUSION There is a critical need to recognize thyroid storm during pregnancy and initiate proper medical interventions promptly.
Collapse
Affiliation(s)
- Vidhu Vadini
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Prabhav Vasistha
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Almog Shalit
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, School of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
- Section of Endocrinology, Central Arkansas Veterans Healthcare System, 4300 W. 7Th St, Little Rock, AR, 72205, USA.
| |
Collapse
|
16
|
Nagakawa K, Soyama A, Hara T, Matsushima H, Imamura H, Tanaka T, Morita M, Kuba S, Adachi T, Hidaka M, Miyaaki H, Akazawa S, Horie I, Sekino M, Hara T, Okano S, Nakao K, Eguchi S. Living donor liver transplantation for a patient with acute liver failure following thyroid storm: a case report. Surg Case Rep 2023; 9:208. [PMID: 38036922 PMCID: PMC10689690 DOI: 10.1186/s40792-023-01786-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Thyroid storm can be complicated by liver dysfunction, which may occasionally progress to acute liver failure. We herein report a case of acute liver failure following thyroid storm that was treated with living donor liver transplantation after resuscitation from cardiopulmonary arrest. CASE REPORT The patient was a woman in her 40 s who had been diagnosed with an abnormal thyroid function. She suffered from fatigue and vomiting, and was found to have consciousness disorder, a fever, and tachycardia with a neck mass. She was diagnosed with thyroid storm and was referred to our hospital. After arrival, she went into cardiopulmonary arrest and veno-arterial extracorporeal membrane oxygenation was initiated. In addition to treatment for thyroid storm with antithyroid drugs, steroids, and plasma exchange, extracorporeal life support was required for 5 days. However, despite improvements in her thyroid function, her liver function deteriorated. We planned living donor liver transplantation for acute liver failure after ensuring the recovery and control of the thyroid function following total thyroidectomy. The donor was her husband who donated the right lobe of his liver. Although she experienced acute cellular rejection after surgery, and other complications-including intra-abdominal hemorrhaging and ischemic changes in the intestine-her liver function and general condition gradually improved. One year after living donor liver transplantation, the patient was in a good condition with a normal liver function. CONCLUSIONS To our knowledge, this is the first report of living donor liver transplantation in a patient with acute liver failure following thyroid storm. Liver transplantation should be recognized as an effective treatment for acute liver failure following thyroid storm.
Collapse
Affiliation(s)
- Kantoku Nagakawa
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan.
| | - Takanobu Hara
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Hajime Matsushima
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Hajime Imamura
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Takayuki Tanaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Michi Morita
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Sakaya Kuba
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoru Akazawa
- Division of Endocrinology and Metabolism, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ichiro Horie
- Division of Endocrinology and Metabolism, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinji Okano
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| |
Collapse
|
17
|
Makino M, Koriyama N, Kojima N, Nishio Y. A Rare Case of Painless Destructive Thyroiditis Resulting in Thyroid Storm. Intern Med 2023; 62:3373-3379. [PMID: 37032084 DOI: 10.2169/internalmedicine.1496-22] [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: 04/11/2023] Open
Abstract
Thyroid storm is a life-threatening clinical condition that is usually triggered by untreated or interrupted treatment of Graves' disease, leading to the sudden onset of severe thyrotoxicosis, which requires an immediate diagnosis and treatment based on diagnostic criteria. Cases of thyroid storm caused by painless/painless subacute thyroiditis are very rare. We herein report an 85-year-old man with features of severe thyrotoxicosis caused by painless/painless subacute thyroiditis who had no uptake of 99mTcO4 and was negative for thyroid-stimulating hormone receptor antibodies. In thyroid storm patients in whom the findings are inconsistent with Graves' disease, careful follow-up and management are necessary, assuming the possibility of painless or painless subacute thyroiditis.
Collapse
Affiliation(s)
- Miwa Makino
- Department of Diabetes and Endocrinology, National Hospital Organization, Kagoshima Medical Center, Japan
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, Japan
| | - Nobuyuki Koriyama
- Department of Diabetes and Endocrinology, National Hospital Organization, Kagoshima Medical Center, Japan
| | - Nami Kojima
- Department of Diabetes and Endocrinology, National Hospital Organization, Kagoshima Medical Center, Japan
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, Japan
| | - Yoshihiko Nishio
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, Japan
| |
Collapse
|
18
|
AlShehri S, Bafadel M, Aljohani N. Therapeutic Plasma Exchange in Refractory Atrial Fibrillation Secondary to a Thyroid Storm. Cureus 2023; 15:e49109. [PMID: 38125237 PMCID: PMC10732184 DOI: 10.7759/cureus.49109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Thyrotoxic crisis (thyroid storm) is a severe form of hyperthyroidism. It has a wide range of symptoms, including cardiovascular manifestations that can be life-threatening and require prompt management. Cardiac manifestations of thyroid storm include hypertension, tachycardia, congestive heart failure, cardiac ischemia, and atrial fibrillation. Standard therapeutic approaches of thyroid storm are based on the use of thionamides, corticosteroids, and nonselective beta-blockers to inhibit thyroid hormone synthesis and release while also blocking thyroxin's peripheral effects. This approach is an effective measure in the management of these manifestations. However, when a patient fails to respond to conventional therapy, or there is end organ damage and surgery is not feasible, therapeutic plasma exchange (TPE) is a life-saving measure. Here, we report a case of a 27-year-old female who is known to have hyperthyroidism, but she was not compliant with her medication. She presented with symptoms of hyperthyroidism and was found to have a thyroid storm with refractory atrial fibrillation. Despite the effort to control her symptoms, she developed cardiac arrest, and after 15 minutes of cardiopulmonary resuscitation, she was revived. Amiodarone, beta-blockers, and cardioversion failed to improve the patient's status, and her condition deteriorated. So, we decided to use TPE, and she received three sessions in total. After the first session of TPE, her rhythm converted to sinus rhythm, and her heart rate was controlled to less than 100 beats per minute. She showed dramatic improvement clinically and biochemically. In conclusion, cardiac complications are potentially lethal complications of thyroid storm. Prompt restoration of a normal thyroid state can reverse these complications. When conventional therapy fails to ameliorate symptoms or organ deterioration is rapid and severe, TPE can be a safe and effective measure.
Collapse
Affiliation(s)
- Sara AlShehri
- Endocrinology, Diabetes, and Metabolism, Princess Nourah Bint Abdulrahman University, Riyadh, SAU
| | - Marwah Bafadel
- Endocrinology and Diabetes, King Fahad Medical City, Riyadh, SAU
| | - Naji Aljohani
- Obesity, Endocrine, and Metabolism Centre, King Fahad Medical City, Riyadh, SAU
- College of Medicine, Alfaisal University, Riyadh, SAU
| |
Collapse
|
19
|
Kwon SH, Kim MJ, Jung SY, Jeon JH. Thyroid storm caused by metastatic papillary thyroid carcinoma tissue after total thyroidectomy: a case report. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2023; 40:S93-S97. [PMID: 37194238 DOI: 10.12701/jyms.2023.00199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/30/2023] [Indexed: 05/18/2023]
Abstract
Thyroid storm is a life-threatening form of thyrotoxicosis and an endocrinological emergency. We present a case of thyroid storm in a patient with metastatic papillary thyroid cancer. A 67-year-old woman with a history of total thyroidectomy 4 years prior to presentation was admitted with deteriorating mental status, fever, and tachycardia. Laboratory tests revealed severe thyrotoxicosis. Although the patient had no residual thyroid tissue after total thyroidectomy, she had a previously diagnosed metastatic thyroid cancer lesion in the pelvic bone. Despite initial treatment with a standard thyroid storm regimen, the patient died 6 days after hospitalization. The patient had no history of Graves disease; however, a thyroxine receptor antibody was detected postmortem. The patient had a history of exposure to an iodine contrast agent, which is a rare cause of thyrotoxicosis. Thyroxine production from a differentiated thyroid carcinoma is rare but can be a source of clinically significant thyrotoxicosis in patients post-thyroidectomy. Overlapping Graves disease is a common stimulus; however, other causes, such as exogenous iodine, cannot be excluded. This case demonstrates that in the setting of metastatic thyroid carcinoma, thyrotoxicosis cannot be completely ruled out as a cause of suspicious symptoms, even in patients with a history of total thyroidectomy.
Collapse
Affiliation(s)
- So Hee Kwon
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min-Ji Kim
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sin Yeong Jung
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae-Han Jeon
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
20
|
Inman BL, Long B. Thyrotoxicosis. Emerg Med Clin North Am 2023; 41:759-774. [PMID: 37758422 DOI: 10.1016/j.emc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturbances, and hyperthermia. Management of subclinical hyperthyroidism and thyrotoxicosis without thyroid storm is heavily dependent on outpatient evaluation. Thyroid storm is the most severe form of hyperthyroidism with the highest mortality. Management of thyroid storm follows a stepwise approach, with resuscitation and detection of the precipitating cause being paramount. Special attention should be paid to cardiac function in patients with thyroid storm before treatment, as these patients may develop cardiac collapse.
Collapse
Affiliation(s)
- Brannon L Inman
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Campennì A, Avram AM, Verburg FA, Iakovou I, Hänscheid H, de Keizer B, Petranović Ovčariček P, Giovanella L. The EANM guideline on radioiodine therapy of benign thyroid disease. Eur J Nucl Med Mol Imaging 2023; 50:3324-3348. [PMID: 37395802 PMCID: PMC10542302 DOI: 10.1007/s00259-023-06274-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023]
Abstract
This document provides the new EANM guideline on radioiodine therapy of benign thyroid disease. Its aim is to guide nuclear medicine physicians, endocrinologists, and practitioners in the selection of patients for radioiodine therapy. Its recommendations on patients' preparation, empiric and dosimetric therapeutic approaches, applied radioiodine activity, radiation protection requirements, and patients follow-up after administration of radioiodine therapy are extensively discussed.
Collapse
Affiliation(s)
- Alfredo Campennì
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Unit of Nuclear Medicine, University of Messina, Messina, Italy
| | - Anca M Avram
- Departments of Radiology and Medicine, MetroHealth Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Frederik A Verburg
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Ioannis Iakovou
- Academic Department of Nuclear Medicine, University Hospital AHEPA, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Academic Department of Nuclear Medicine, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Heribert Hänscheid
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Petra Petranović Ovčariček
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luca Giovanella
- Clinic for Nuclear Medicine, Ente Ospedaliero Cantonale, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| |
Collapse
|
23
|
Joseph AM, Karas M, Camba VH, Martin BM, Preece J. Anchoring on Hyperglycemia and Sepsis in the Presence of an Unforeseen Thyroid Storm. Cureus 2023; 15:e46138. [PMID: 37900434 PMCID: PMC10612572 DOI: 10.7759/cureus.46138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Thyroid storm (TS) is a relatively rare but life-threatening complication of an overactive thyroid that can manifest in a myriad of ways due to its multisystem involvement. Due to its relatively high mortality rate, it is essential that TS is recognized and treated promptly. TS can occur due to trauma, drugs, and sepsis. Identifying TS as a diagnosis is challenging to pinpoint due to its similar presentation to more common pathologies like sepsis and diabetic ketoacidosis (DKA). Here, we present a case of a 31-year-old African-American woman with type 2 diabetes mellitus following sepsis secondary to Escherichia coli pyelonephritis and DKA. Despite standard sepsis treatment, which included appropriate intravenous fluids and antibiotics, the patient did not improve. Further workup, utilizing the Burch-Wartofsky score, helped identify TS as the underlying cause of the patient's hospitalization, despite no history of underlying thyroid disease. The inclusion of thyroid pathology as part of the differential diagnosis and workup of a patient with a sepsis-like presentation to avoid anchoring bias warrants further investigation.
Collapse
Affiliation(s)
- Andrew M Joseph
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Monica Karas
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Victor H Camba
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Brian M Martin
- Graduate Medical Education, Magnolia Regional Health Center, Corinth, USA
| | - John Preece
- Internal Medicine, Magnolia Regional Health Center, Corinth, USA
| |
Collapse
|
24
|
Eltahir M, Chaudhry H, Ibrahim EA, Mokhtar M, Jaouni H, Hassan IF, El-Menyar A, Shehatta AL. Thyroid Storm-Induced Refractory Multiorgan Failure Managed by Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case-Series. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e940672. [PMID: 37614021 PMCID: PMC10461322 DOI: 10.12659/ajcr.940672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/17/2023] [Accepted: 06/22/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Severe hyperthyroidism, including thyroid storm, can be precipitated by acute events, such as surgery, trauma, infection, medications, parturition, and noncompliance or stoppage of antithyroid drugs. Thyroid storm is one of the serious endocrinal emergencies that prompts early diagnosis and treatment. Early occurrence of multiorgan failure is an ominous sign that requires aggressive treatment, including the initiation of extracorporeal membrane oxygenation (ECMO) support as a bridge to stability and definitive surgical treatment. Most adverse events occur after failure of medical therapy. CASE REPORT We described 4 cases of fulminating thyroid storm that were complicated with multiple organ failure and cardiac arrest. The patients, 3 female and 1 male, were between 39 and 46 years old. All patients underwent ECMO support, with planned thyroidectomy. Three survived to discharge and 1 died after prolonged cardiac arrest and sepsis. All patients underwent peripheral, percutaneous, intensivist-led cannulation for VA-ECMO with no complications. CONCLUSIONS Early recognition of thyroid storm, identification of the cause, and proper treatment and support in the intensive care unit is essential. Patients with thyroid storm and cardiovascular collapse, who failed to improve with conventional supportive measures, had the worst prognosis, and ECMO support should be considered as a bridge until the effective therapy takes effect. Our case series showed that, in patients with life-threatening thyroid storm, VA-ECMO can be used as bridge to stabilization, definitive surgical intervention, and postoperative endocrine management. Interprofessional team management is essential, and early implantation of VA-ECMO is likely beneficial in patients with thyroid storm after failure of conventional management.
Collapse
Affiliation(s)
- Mugahid Eltahir
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hamza Chaudhry
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ezzeddin Abdulsalam Ibrahim
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Marwa Mokhtar
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hani Jaouni
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
- Department of Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Labib Shehatta
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| |
Collapse
|
25
|
Farooqi S, Raj S, Koyfman A, Long B. High risk and low prevalence diseases: Thyroid storm. Am J Emerg Med 2023; 69:127-135. [PMID: 37104908 DOI: 10.1016/j.ajem.2023.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/12/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Thyroid storm is a rare but serious condition that carries a high rate of morbidity and even mortality. OBJECTIVE This review highlights the pearls and pitfalls of thyroid storm, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Thyroid storm is a challenging condition to diagnose and manage in the ED. It is characterized by exaggerated signs and symptoms of thyrotoxicosis and evidence of multiorgan decompensation, usually occurring in the presence of an inciting trigger. Clinical features of thyroid storm may include fever, tachycardia, signs of congestive heart failure, vomiting/diarrhea, hepatic dysfunction, and central nervous system disturbance. There are several mimics including sympathomimetic overdose, substance use disorders, alcohol withdrawal, acute pulmonary edema, aortic dissection, heat stroke, serotonin syndrome, and sepsis/septic shock. Ultimately, the key to diagnosis is considering the disease. While laboratory assessment can assist, there is no single laboratory value that will establish a diagnosis of thyroid storm. Clinical criteria include the Burch-Wartofsky point scale and Japan Thyroid Association diagnostic criteria. ED treatment focuses on diagnosing and managing the trigger; resuscitation; administration of steroids, thionamides, iodine, and cholestyramine; and treatment of hyperthermia and agitation. Beta blockers should be administered in the absence of severe heart failure. The emergency clinician should be prepared for rapid clinical deterioration and employ a multidisciplinary approach to treatment that involves critical care and endocrinology specialists. CONCLUSIONS An understanding of thyroid storm can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Collapse
Affiliation(s)
- Samia Farooqi
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Sonika Raj
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| |
Collapse
|
26
|
Aoki Y, Hanaki R, Toyoda H, Emori K, Miyahara M, Hirayama M. Case report: Thyroid storm in a three-year-old girl presenting with febrile status epilepticus and hypoglycemia. Front Pediatr 2023; 11:1213040. [PMID: 37397147 PMCID: PMC10311634 DOI: 10.3389/fped.2023.1213040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Thyroid storm, though extremely rare in toddlers, requires prompt diagnosis and treatment because it can be fatal if left untreated. However, thyroid storm is not often considered in the differential diagnosis of a febrile convulsion due to its rarity in children. Herein, we report the case of a 3-year-old girl with thyroid storm who presented with febrile status epilepticus. Although the seizure was stopped by diazepam administration, her tachycardia and widened pulse pressure persisted, and severe hypoglycemia was observed. Based on the findings of thyromegaly, a history of excessive sweating and hyperactivity, and a family history of Graves' disease, she was eventually diagnosed with a thyroid storm. The patient was successfully treated with thiamazole, landiolol, hydrocortisone, and potassium iodide. Propranolol, a non-selective β-blocker, has been used to manage tachycardia during thyroid storm. However, a cardio-selective β1-blockers, landiolol hydrochloride, was used in our case to avoid worsening hypoglycemia. Febrile status epilepticus is one of the most common medical emergencies in childhood; it is necessary to rule out treatable underlying critical diseases such as septic meningitis and encephalitis. Thyroid storm should be considered in children presenting with prolonged febrile convulsion accompanied by findings that are not usually observed with febrile convulsions.
Collapse
Affiliation(s)
- Yusuke Aoki
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryo Hanaki
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hidemi Toyoda
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Koichi Emori
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
- Department of Pediatrics, Okanami General Hospital, Iga, Japan
| | | | - Masahiro Hirayama
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
27
|
Pimentel Campillo J, Corona Castillo D, Nunez M, Finke Abbott A, Pichardo J. Pneumonia-Induced Thyroid Crisis With Thyrotoxicosis Exacerbation: De Novo Graves' Disease Presentation on a Cornelia de Lange Syndrome (CdLS). Cureus 2023; 15:e41119. [PMID: 37519569 PMCID: PMC10382790 DOI: 10.7759/cureus.41119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Cornelia de Lange syndrome (CdLS) is a rare genetic disorder that affects multiple organ systems and is characterized by distinctive facial features, growth retardation, and developmental disabilities. The syndrome is caused by mutations in genes (NIPBL, RAD21, SMC3, HDAC8, and SMC1A) involved in the cohesin complex, which plays a critical role in chromosome segregation and gene expression regulation. Clinical findings typically include dysmorphic facial features (arched eyebrows, synophrys, long eyelashes, ptosis, long philtrum, thin upper lip, and posteriorly rotated ears), growth and mental retardation, upper limb defects (clinodactyly and limb deficiencies), gastrointestinal complications (gastroesophageal reflux, pyloric stenosis, diaphragmatic hernia, malrotation, and volvulus), and heart defects (ventricular and atrial septal defects). In addition, chronic respiratory tract infections including sinusitis and pneumonia have been frequently described in this population. The early recognition and diagnosis of CdLS through genetic testing are crucial to ensure appropriate medical management and early intervention therapies to improve the outcomes of affected individuals. The thyroid gland is not affected by this congenital disease, but complications can arrive in this organ by other disease-related organ malfunctions. Pneumonia-induced thyroiditis is a potentially life-threatening condition that can occur in patients with underlying thyroid disease who also develop pneumonia. The symptoms are due to the hypermetabolic state induced by excess thyroid hormones and include weight loss, heat intolerance, and palpitations. There are many different causes of thyrotoxicosis. It is important to determine the cause since treatment is based on the underlying etiology. The diagnosis of pneumonia-induced thyrotoxicosis can be challenging as symptoms may mimic other conditions and laboratory testing may not always provide a clear answer. The diagnosis is confirmed with low thyroid-stimulating hormone (TSH) and elevated free thyroxine (T4) and triiodothyronine (T3), erythrocyte sedimentation rate (ESR), and C-reactive protein. The management of the condition involves prompt recognition, supportive care, and the use of medications to lower thyroid hormone levels, such as beta-blockers, antithyroid drugs, steroids, and iodine. In severe cases, plasmapheresis or thyroidectomy may be necessary.
Collapse
Affiliation(s)
- Jorge Pimentel Campillo
- Internal Medicine, Centros de Diagnóstico y Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT), Santo Domingo, DOM
| | - Daneybi Corona Castillo
- Endocrinology, Diabetes, and Metabolism, Centros de Diagnóstico y Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT), Santo Domingo, DOM
| | - Marco Nunez
- Pediatrics, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Jesús Pichardo
- Surgery and Specialties, Centros de Diagnóstico y Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT), Santo Domingo, DOM
| |
Collapse
|
28
|
Metwalley KA, Farghaly HS. Graves' Disease in Children: An Update. Clin Med Insights Endocrinol Diabetes 2023; 16:11795514221150615. [PMID: 37151843 PMCID: PMC10161304 DOI: 10.1177/11795514221150615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/23/2022] [Indexed: 05/09/2023] Open
Abstract
Graves' disease (GD) is the most common cause of hyperthyroidism in children. A common GD symptom is a goiter. The usual biochemical profile in children with GD is a decreased thyroid hormone stimulating hormone (TSH) level and high free thyroxine (FT4) and free triiodothyronine (FT3) concentrations. The presence of thyroid receptor antibodies (TRAb) is the most important specific immunological sign for diagnosing GD. The treatment choices for pediatric GD are anti-thyroid drugs (ATDs), radioiodine, and thyroidectomy, but the risks and benefits of each modality are different. Management recommendations include the first-line use of a prolonged course of ATDs for at least 3 years and potentially 5 years or more. Rituximab and Teprotumumab are new novel alternative medications for the treatment of adult patients with GD and Graves' orbitopathy respectively, but evidence of the efficacy and safety of these drugs in pediatric patients with GD is lacking.
Collapse
Affiliation(s)
| | - Hekma Saad Farghaly
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| |
Collapse
|
29
|
Rushing MW, Rebolledo MA, Lahoti A, Alemzadeh R. Acute febrile illness in a teenage female with history of Graves' disease. Oxf Med Case Reports 2023; 2023:omad050. [PMID: 37260732 PMCID: PMC10228105 DOI: 10.1093/omcr/omad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/08/2023] [Accepted: 03/31/2023] [Indexed: 06/02/2023] Open
Abstract
Thyroid storm is a rare, life-threatening condition that is usually precipitated by Graves' disease in children and adolescents. COVID-19 (SARS-CoV-2) can cause multisystem inflammatory syndrome in children (MIS C), which shares some features of Graves' disease. We present a case of acute thyroid storm following SARS-CoV-2 infection in a 16-year-old female with poorly controlled Graves' disease. She initially presented to the emergency department for fever and palpitations. Initial laboratory results suggested thyroid storm, for which she was started on propranolol. She remained tachycardic with new gallop rhythm on exam. An echocardiogram demonstrated a depressed left ventricular ejection fraction and mild pulmonary hypertension. Her SARS-CoV-2 antibodies were positive. She was started on intravenous immunoglobulin for suspected MIS-C. She responded to combined treatment of thyroid storm and MIS-C. She was discharged home on propranolol, methimazole, cholestyramine and aspirin.
Collapse
Affiliation(s)
- Mark W Rushing
- Correspondence address. Department of Pediatrics, Division of Pediatric Cardiology, The University of Tennessee Health Science Center, Division of Pediatric Cardiology, Faculty Office Building, 9 N. Dunlap St., 3rd floor, Memphis, TN 38103, USA. Tel: 901.287.6034; Fax: 901.287.5062; E-mail:
| | - Michael A Rebolledo
- Department of Pediatrics, Division of Pediatric Cardiology, The University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Amit Lahoti
- Department of Pediatrics, Division of Pediatric Endocrinology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Ramin Alemzadeh
- Department of Pediatrics, Division of Pediatric Endocrinology, The University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| |
Collapse
|
30
|
Lee SY, Modzelewski KL, Law AC, Walkey AJ, Pearce EN, Bosch NA. Comparison of Propylthiouracil vs Methimazole for Thyroid Storm in Critically Ill Patients. JAMA Netw Open 2023; 6:e238655. [PMID: 37067797 PMCID: PMC10111182 DOI: 10.1001/jamanetworkopen.2023.8655] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Importance Thyroid storm is the most severe form of thyrotoxicosis, with high mortality, and is treated with propylthiouracil and methimazole. Some guidelines recommend propylthiouracil over methimazole, although the difference in outcomes associated with each treatment is unclear. Objective To compare outcomes associated with use of propylthiouracil vs methimazole for the treatment of thyroid storm. Design, Setting, and Participants This comparative effectiveness study comprised a large, multicenter, US-based cohort from the Premier Healthcare Database between January 1, 2016, and December 31, 2020. It included 1383 adult patients admitted to intensive or intermediate care units with a diagnosis of thyroid storm per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes and treated with either propylthiouracil or methimazole. Analyses were conducted from July 2022 to February 2023. Exposure Patients received either propylthiouracil or methimazole for treatment of thyroid storm. Exposure was assigned based on the initial thionamide administered. Main Outcomes and Measures The primary outcome was the adjusted risk difference of in-hospital death or discharge to hospice between patients treated with propylthiouracil and those treated with methimazole, assessed by targeted maximum likelihood estimation. Results A total of 1383 patients (656 [47.4%] treated with propylthiouracil; mean [SD] age, 45 [16] years; 473 women [72.1%]; and 727 [52.6%] treated with methimazole; mean [SD] age, 45 [16] years; 520 women [71.5%]) were included in the study. The standardized mean difference for age was 0.056, and the standardized mean difference for sex was 0.013. The primary composite outcome occurred in 7.4% of of patients (102 of 1383; 95% CI, 6.0%-8.8%). A total of 8.5% (56 of 656; 95% CI, 6.4%-10.7%) of patients who initiated propylthiouracil and 6.3% (46 of 727; 95% CI, 4.6%-8.1%) who initiated methimazole died in the hospital (adjusted risk difference, 0.6% [95% CI, -1.8% to 3.0%]; P = .64). There were no significant differences in duration of organ support, total hospitalization costs, or rates of adverse events between the 2 treatment groups. Conclusion and Relevance In this comparative effectiveness study of a multicenter cohort of adult patients with thyroid storm, no significant differences were found in mortality or adverse events in patients who were treated with propylthiouracil or methimazole. Thus, current guidelines recommending propylthiouracil over methimazole for treatment of thyroid storm may merit reevaluation.
Collapse
Affiliation(s)
- Sun Y. Lee
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Katherine L. Modzelewski
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Anica C. Law
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Allan J. Walkey
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Elizabeth N. Pearce
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Nicholas A. Bosch
- Department of Medicine, The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| |
Collapse
|
31
|
Seffah K, Lamptey R, Ibrahim S, Agyeman WY, Addo B. The Thyroid Forecast: A Case of a Thyroid Storm Diagnosed Under Unforeseen Circumstances. Cureus 2023; 15:e37707. [PMID: 37206496 PMCID: PMC10191387 DOI: 10.7759/cureus.37707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Hyperthyroidism and thyrotoxicosis are common conditions in clinical practice. Untreated, they are associated with several co-morbidities. One of these conditions, and arguably the most lethal, is the thyroid storm. Our case presentation is one of a young female who had previously been diagnosed with thyroid illness but was lost to follow-up, subsequently given a clean bill of health, and emerged with what would eventually be diagnosed as a thyroid storm. While the thyroid storm may pose some diagnostic challenges, it has come a long way in securing diagnostic tools. What remains is a tool for physicians and patients to stratify patients by their risk of developing a storm in the outpatient setting.
Collapse
Affiliation(s)
- Kofi Seffah
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Robert Lamptey
- Trauma and Emergency, Korle-Bu Teaching Hospital, Accra, GHA
| | - Sammudeen Ibrahim
- Graduate Medical Education, Piedmont Athens Regional Medical Center, Athens, USA
| | - Walter Y Agyeman
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Basilio Addo
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| |
Collapse
|
32
|
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.
Collapse
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.
| |
Collapse
|
33
|
Abisad DA, Glenn Lecea EM, Ballesteros AM, Alarcon G, Diaz A, Pagan-Banchs P. Thyroid storm in pediatrics: a systematic review. J Pediatr Endocrinol Metab 2023; 36:225-233. [PMID: 36318760 DOI: 10.1515/jpem-2022-0309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Thyroid storm (TS) is an uncommon but severe manifestation of hyperthyroidism and an endocrine emergency, as it is fatal if it goes unrecognized. In pediatrics, the current literature is limited to case reports and case series. Current knowledge is extrapolated from adult data. This systematic review aims to present the epidemiology, most common etiologies, clinical presentation, and most accepted standard of care of TS in children. We aim to raise awareness of hyperthyroidism in the pediatric community. CONTENT The databases used were PubMed, google scholar, and LILACS, with the search terms "thyroid storm" AND "pediatrics". Studies included case reports and case series in English and Spanish from patients between the ages of 0-21 years with clinical features consistent with a diagnosis of TS based on ATA 2016, with or without reported scale scores, published between 2000 and 2022. Variables such as ethnicity, etiology, possible triggers, clinical features, and management components were analyzed and presented. SUMMARY We analyzed data from 45 patients. Their mean age was 11.25 years. The majority of them were from Asia (26%). The most common clinical features were sinus tachycardia (86.7%) and fever (64%), followed by altered mental status (46%) and diarrhea (31%). Graves' disease was the most common underlying condition, and infection the most common precipitant. Thirty one percent of patients received treatment with four components; however morbidity and mortality were not clinically significant with those who did not. TS has a heterogeneous presentation with multisystemic involvement. The most common symptoms in this review were fever, tachycardia, diarrhea, and altered mental status. OUTLOOK Further studies may be needed to best standardize the diagnosis and management of TS in children. Qualitative studies are needed to best assess the delay in diagnosis of hyperthyroidism and how this may impact prognosis in case patients were to develop TS.
Collapse
Affiliation(s)
| | | | | | - Guido Alarcon
- Pediatric Endocrinology, Baylor College of Medicine, Houston, TX, USA
| | - Alejandro Diaz
- Pediatric Endocrinology, Nicklaus Children's Hospital, Miami, FL, USA
| | | |
Collapse
|
34
|
Yamazaki D, Osaki Y, Suzuki H, Shimano H. Takotsubo cardiomyopathy with left ventricle thrombus caused by subacute thyroiditis. BMJ Case Rep 2023; 16:e250540. [PMID: 36918211 PMCID: PMC10016297 DOI: 10.1136/bcr-2022-250540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
We report a rare case of takotsubo cardiomyopathy caused by subacute thyroiditis in a man in his 50s. He went to the doctor with complaints of loss of appetite, diarrhoea, chills and general malaise. He had consciousness disturbance, thyrotoxicosis and thyroid-stimulating hormone (TSH) suppression. Thyroglobulin and C reactive protein levels in the blood were elevated, but TSH receptor antibody, thyroid-stimulating antibody, antithyroglobulin antibody and antithyroid peroxidase antibody were not. We began treatment with prednisolone and propranolol after he was diagnosed with thyroid storm caused by subacute thyroiditis. The ECG revealed inverted T waves on the fifth day after admission. He was newly diagnosed with takotsubo cardiomyopathy on the day. A large thrombus was detected in the left ventricle, requiring anticoagulation therapy. Thus, even if there are no findings of takotsubo cardiomyopathy or thrombus at the onset of thyroid storm, appropriate monitoring is required because they can develop during the treatment course.
Collapse
Affiliation(s)
- Daichi Yamazaki
- Internal Medicine (Endocrinology and Metabolism), University of Tsukuba, Tsukuba, Japan
| | - Yoshinori Osaki
- Internal Medicine (Endocrinology and Metabolism), University of Tsukuba, Tsukuba, Japan
| | - Hiroaki Suzuki
- Internal Medicine (Endocrinology and Metabolism), University of Tsukuba, Tsukuba, Japan
| | - Hitoshi Shimano
- Internal Medicine (Endocrinology and Metabolism), University of Tsukuba, Tsukuba, Japan
| |
Collapse
|
35
|
Tizianel I, Sabbadin C, Censi S, Clausi C, Colpo A, Leahu AI, Iacobone M, Mian C, Scaroni C, Ceccato F. Therapeutic Plasma Exchange for the Treatment of Hyperthyroidism: Approach to the Patient with Thyrotoxicosis or Antithyroid-Drugs Induced Agranulocytosis. J Pers Med 2023; 13:jpm13030517. [PMID: 36983698 PMCID: PMC10056870 DOI: 10.3390/jpm13030517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
Abstract
Primary hyperthyroidism is an endocrine disorder characterized by excessive thyroid hormone synthesis and secretion by the thyroid gland. Clinical manifestations of hyperthyroidism can vary from subclinical to overt forms. In rare cases, hyperthyroidism may represent a clinical emergency, requiring admission to an intensive care unit due to an acute and severe exacerbation of thyrotoxicosis, known as a thyroid storm. First-line treatment of hyperthyroidism is almost always based on medical therapy (with thioamides, beta-adrenergic blocking agents, glucocorticoids), radioactive iodine or total thyroidectomy, tailored to the patient’s diagnosis. In cases of failure/intolerance/adverse events or contraindication to these therapies, as well as in life-threatening situations, including a thyroid storm, it is necessary to consider an alternative treatment with extracorporeal systems, such as therapeutic plasma exchange (TPE). This approach can promptly resolve severe conditions by removing circulating thyroid hormones. Here we described two different applications of TPE in clinical practice: the first case is an example of thyrotoxicosis due to amiodarone treatment, while the second one is an example of a severe adverse event to antithyroid drugs (agranulocytosis induced by methimazole).
Collapse
Affiliation(s)
- Irene Tizianel
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Chiara Sabbadin
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Simona Censi
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Cristina Clausi
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Anca Irina Leahu
- Department of Transfusion Medicine, Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology (DISCOG), Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Caterina Mian
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Carla Scaroni
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8211323
| |
Collapse
|
36
|
Ohya A, Ohtake M, Kawamura Y, Akimoto T, Iwashita M, Yamamoto T, Takeuchi I. Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report. Int J Emerg Med 2023; 16:15. [PMID: 36858963 PMCID: PMC9976426 DOI: 10.1186/s12245-023-00490-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. CASE PRESENTATION The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient's symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient's condition. CONCLUSION If a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient's condition is critical, and early diagnosis will lead to a favorable outcome for the patient.
Collapse
Affiliation(s)
- Aimi Ohya
- grid.413045.70000 0004 0467 212XDepartment of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Japan
| | - Makoto Ohtake
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Japan. .,Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan.
| | - Yusuke Kawamura
- grid.413045.70000 0004 0467 212XDepartment of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Japan
| | - Taisuke Akimoto
- grid.413045.70000 0004 0467 212XDepartment of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Masayuki Iwashita
- grid.413045.70000 0004 0467 212XDepartment of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuya Yamamoto
- grid.268441.d0000 0001 1033 6139Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ichiro Takeuchi
- grid.413045.70000 0004 0467 212XDepartment of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Japan
| |
Collapse
|
37
|
Hyperthyroidism and depression: a clinical case of atypical thyrotoxicosis manifestation. Int Clin Psychopharmacol 2023:00004850-990000000-00044. [PMID: 36853810 DOI: 10.1097/yic.0000000000000438] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The relationship between psychiatric symptoms and thyroid function has been well known and studied since antiquity. The common view is that clinical hypothyroidism is associated with depressive symptoms, whereas the psychiatric manifestations of hyperthyroidism are agitation, emotional lability, hyperexcitability, occasionally accompanied by angry outbursts, and euphoria. The case here reported overturns this conventional medical knowledge. A 73-year-old Italian woman experienced a severe major depressive episode with psychotic and melancholic features during laboratory thyrotoxicosis. No classical clinical signs and symptoms of thyrotoxicosis were present. Psychiatric symptoms improved together with the resolution of the hyperthyroid state. Historically, different cases of so-called 'apathetic hyperthyroidism' have been described. Recent neuroimaging and animal studies provided possible neurobiological explanations, showing how the excess thyroid hormones could affect brain structures involved in the regulation of mood, leading to depression. A direct link between hyperthyroidism and depression seems to be likely. This insight may be relevant in facilitating early diagnosis of thyroid disease and the planning of therapeutic strategies.
Collapse
|
38
|
Wang Y, Sun Y, Yang B, Wang Q, Kuang H. The management and metabolic characterization: hyperthyroidism and hypothyroidism. Neuropeptides 2023; 97:102308. [PMID: 36455479 DOI: 10.1016/j.npep.2022.102308] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Hyperthyroidism and hypothyroidism are common diseases resulting from thyroid dysfunction, and are simple to diagnose and treat. The traditional treatment for hypothyroidism is thyroid hormone replacement therapy. The traditional treatments for hyperthyroidism include antithyroid drug, iodine radiotherapy, and surgery. Thyroid disease can be fatal in severe cases if untreated. Current statistical reference ranges used for diagnosis based on relevant biochemical parameters have been debated, and insufficient treatment can result in long-term thyroid hormone deficiency, which is associated with increased risk of cardiovascular disease and persistent symptoms. In contrast, overtreatment can result in heart disease and osteoporosis, particularly in older people and pregnant women. Therefore, under- or over-treatment should be avoided and treatment regimens should be monitored closely. A significant proportion of patients who achieve biochemical treatment goals still complain of significant symptoms. Systematic literature review was performed through the Embase (Elsevier), PubMed and Web of Science databases, and studies summarized evidence regarding treatment and management of hypothyroidism and hyperthyroidism, and reviewed clinical practice guidelines. We also reviewed the latest research on the metabolic mechanisms of hyperthyroidism and hypothyroidism, which contributed to understanding of thyroid diseases in the clinic. A reliable algorithm is needed to management, assessment, and treatment patients with hyperthyroidism and hypothyroidism, which can not only improve management efficiency, but also providing a broad application. In addition, the thyroid disorder showed a lipid metabolism tissue specificity in the Ventromedial Hypothalamus, and effect oxidative stress and energy metabolism of whole body. This review summarizes an algorithm for thyroid disease and the latest pathogenesis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition.
Collapse
Affiliation(s)
- Yangyang Wang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - YanPing Sun
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - Bingyou Yang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - Qiuhong Wang
- School of Traditional Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou, China.
| | - Haixue Kuang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China.
| |
Collapse
|
39
|
Wijeratne S, Chong C, Kirthinanda DS. Anaesthesiology perspective on a multidisciplinary approach to optimal perioperative management of a patient with giant peptic ulcer perforation caused by the physiological stress of a thyroid storm necessitating emergent laparotomy. BMJ Case Rep 2022; 15:e250816. [PMID: 36585054 PMCID: PMC9809235 DOI: 10.1136/bcr-2022-250816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Thyroid storm is a rare, fatal complication of thyrotoxicosis that necessitates aggressive medical treatment. We present a case of a patient who developed duodenal ulcer perforation as a result of a thyroid storm caused by Graves' thyrotoxicosis. In addition to life-threatening intra-abdominal sepsis complicated by high anion-gap metabolic acidosis, he was found to have severely deranged thyroid hormone levels and clinical features compatible with thyroid storm based on the Burch-Wartofsky Score. Diagnosis and management of such patients with compromised gastrointestinal (GI) tract present a remarkable clinical challenge to the anaesthetist and the intensivists. Multidisciplinary care with rapid preoperative optimisation, careful intraoperative anaesthetic techniques and postoperative care resulted in excellent outcomes. This case report sheds light on how to tailor general anaesthesia to minimise physiological derangement associated with thyroid storm and re-establish homeostasis in patients presenting for emergent surgery, particularly those with GI dysfunction.
Collapse
Affiliation(s)
- Sujani Wijeratne
- Department of Anaesthesia, Intensive Care and Pain Medicine, Khoo Teck Puat Hospital, Singapore
| | - Claudia Chong
- Department of Anaesthesia, Intensive Care and Pain Medicine, Khoo Teck Puat Hospital, Singapore
| | | |
Collapse
|
40
|
Thiyagarajan A, Platzbecker K, Ittermann T, Völzke H, Haug U. Estimating Incidence and Case Fatality of Thyroid Storm in Germany Between 2007 and 2017: A Claims Data Analysis. Thyroid 2022; 32:1307-1315. [PMID: 36006371 DOI: 10.1089/thy.2022.0096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Given the paucity of epidemiological studies on thyroid storm, we aimed to estimate the incidence rate and case fatality of thyroid storm in Germany based on a large claims database. Methods: Using the German Pharmacoepidemiological Research Database (GePaRD) we identified patients with at least one inpatient discharge diagnosis of thyroid storm (International Statistical Classification of Diseases and Related Health Problems, 10th revision, German modification; ICD-10-GM E05.5) between 2007 and 2017 and calculated age-standardized and age-specific incidence rates in males and females (no age restriction). We defined deaths occurring within 30 days of the diagnosis as thyroid storm-associated and determined case fatality by sex and age group. Point estimates were reported with confidence intervals [CIs]. Results: We identified 1690 patients with an incident diagnosis of thyroid storm. Of these, 72% were females (n = 1212). The mean age was 60 years (standard deviation: 18.6 years). The age-standardized incidence rate per 100,000 persons per year was 1.4 [CI 1.2-1.7] in females and 0.7 [CI 0.5-0.9] in males. In females ≤60 and >60 years of age, the incidence rate was 0.9 [CI 0.9-1.0] (males: 0.4 [CI 0.3-0.4]) and 2.7 [CI 2.5-2.9] (males: 1.7 [CI 1.5-1.9]), respectively. The case fatality of thyroid storm was 1.4% [CI 0.6-2.8] in females ≤60 years and 10.9% [CI 8.6-13.7] in females >60 years. In males, the case fatality was 1.0% [CI 0.2-4.0] in those aged ≤60 years and 16.7% [CI 12.6-21.7] in those >60 years. Conclusions: Incidence rates of thyroid storm were markedly higher in females than in males and were three times higher in persons >60 years compared with younger age groups. The case fatality was below 2% in persons aged ≤60 years and markedly higher in older persons (males: 17 times and females: 8 times).
Collapse
Affiliation(s)
- Arulmani Thiyagarajan
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Katharina Platzbecker
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| |
Collapse
|
41
|
Hitsuwari T, Tsurutani Y, Yamane T, Sunouchi T, Horikoshi H, Hirose R, Hoshino Y, Watanabe S, Katsuragawa S, Saitou J. Two Cases of Thyrotoxicosis and Euglycemic Diabetic Ketoacidosis Under Sodium-glucose Transport Protein 2 Inhibitor Treatment. Intern Med 2022; 61:3069-3075. [PMID: 35370232 PMCID: PMC9646346 DOI: 10.2169/internalmedicine.8830-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Thyrotoxicosis and sodium-glucose transport protein 2 inhibitors (SGLT2is) are associated with the induction of euglycemic diabetic ketoacidosis (euDKA). We herein report two cases of euDKA in patients with diabetes mellitus wherein both thyrotoxicosis and SGLT2i treatment were the underlying causes. One patient developed thyrotoxicosis during the course of type 2 diabetes mellitus, whereas the other patient was suspected of developing slowly progressive insulin-dependent diabetes mellitus during the course of Graves' disease. Although such cases are rare, there is some concern that similar cases may occur because of the increased frequency of SGLT2i use in recent years.
Collapse
Affiliation(s)
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Takahiro Yamane
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Takashi Sunouchi
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | | | - Rei Hirose
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | | | - Satoshi Watanabe
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Sho Katsuragawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Jun Saitou
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| |
Collapse
|
42
|
Al Khodari K, Tahtouh RA, Hamid T. Acute ST-Elevation Myocardial Infarction in Patient with Severe Uncontrolled Hyperthyroidism Complicated by Thyroid Storm. Heart Views 2022; 23:221-225. [PMID: 36605923 PMCID: PMC9809455 DOI: 10.4103/heartviews.heartviews_8_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 10/09/2022] [Indexed: 01/07/2023] Open
Abstract
Acute ST-elevation myocardial infarction is a life-threatening medical emergency that needs to be recognized early and treated properly to prevent deleterious complications, including death. A thyroid storm (TS) is a rare but severe manifestation of uncontrolled hyperthyroidism that might present with serious cardiovascular or neurological problems. We described a case of a 40-year-old male patient, known to have uncontrolled hyperthyroidism, who presented with acute onset of central chest pain, agitation, tachycardia, and pulmonary congestion. Fast atrial fibrillation with ST-segment elevation in anterior leads was detected on electrocardiogram. Thyroxin level (T4) was very high with undetectable thyroid stimulating hormone. Initially, the patient refused any type of coronary revascularization; therefore, he was admitted to the cardiology intensive care unit, and medical treatment was commenced for both TS and acute coronary syndrome. High-risk coronary angiography was done 2 h later because he had worsening persistent chest pain and started to develop signs of heart failure. It showed embolic occlusion of the distal left anterior descending artery that was treated medically with anti-coagulation. There were no complications. Chest pain and thyroid function tests settled down during his hospital stay with close cardiology and endocrinology follow-up.
Collapse
Affiliation(s)
| | | | - Tahir Hamid
- Department of Cardiology, Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
43
|
Jeevan R, Joshi R, Ramesh J. Anaesthetic implications of a case of hyperthyroidism detected during the closure of an atrial septal defect. BMJ Case Rep 2022; 15:e250427. [PMID: 36130820 PMCID: PMC9494558 DOI: 10.1136/bcr-2022-250427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A woman in her mid-20s who was clinically euthyroid presented with an ostium secondum atrial septal defect for closure. Preoperatively, heart rate ranged from 80 to 110 beats per minute. On the day of surgery, heart rate was 120 beats per minute, which settled after induction. During ultrasound guided central line access, a thyroid swelling was noticed. 20-30 min after commencement of the surgery, heart rate increased up to 130 beats per minute. Since other causes of tachycardia was ruled out, an intraoperative blood sample for thyroid function test was sent. Esmolol was kept ready in case the swelling turned out to be hyperfunctioning thyroid nodule. Post bypass, the patient again developed tachycardia. The thyroid function test showed elevated T3, T4 and a mildly elevated TSH (Thyroid stimulating hormone) value, consistent with an extrathyroid source. The patient is on long-term follow-up under an endocrinologist. Postoperatively, she is again euthyroid and heart rates have settled to less than 100 beats per minute.
Collapse
Affiliation(s)
- Ram Jeevan
- Anesthesiology, Saveetha University Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Reesha Joshi
- Anesthesiology, Saveetha University Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Jayashree Ramesh
- Anesthesiology, Saveetha University Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| |
Collapse
|
44
|
Baik SM, Pae Y, Lee JM. High scored thyroid storm after stomach cancer perforation: A case report. World J Clin Cases 2022; 10:8768-8774. [PMID: 36157821 PMCID: PMC9453375 DOI: 10.12998/wjcc.v10.i24.8768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/20/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Thyroid storm is a life-threatening emergency. Reportedly, the prevalence of thyroid storm is 1%-2% among patients admitted to the hospital for thyrotoxicosis. Burch and Wartofsky (1993) introduced a scoring system using precise clinical criteria to identify thyroid storms. Only 17 cases of thyroid storm with a score > 70 points have been reported. Although thyroid storms are uncommon, their clinical findings resemble those of sepsis.
CASE SUMMARY A 48-year-old man was referred to the emergency room from a local clinic owing to suspicion of gastric ulcer perforation; medications for hypertension, diabetes mellitus, and hyperthyroidism had been suspended 1 year prior to this visit. We performed an emergency distal gastrectomy with Billroth II anastomosis for gastric cardia cancer perforation, and the patient was referred to the surgical intensive care unit (ICU). On the 2nd d in the ICU, his body temperature (BT) increased to 41.3 °C at 19:00, with the thyroid storm score (90 points) peaking at 18:00 (BT; 41.2ºC, pulse rate; 138/min, irritable status). The patient was administered propylthiouracil, intravenous glucocorticoids, acetaminophen, and Lugol’s solution daily. Subsequently, we performed bladder irrigation with cold saline using a Foley catheter and applied a hypothermic blanket to decrease the patient's BT. His vital signs were stable on the 8th day in the ICU.
CONCLUSION Thyroid storms are uncommon, with few reports in the literature; however, their clinical findings resemble those of sepsis and require further investigation. Since an untreated thyroid storm results in a high mortality rate, it should be investigated when managing sepsis.
Collapse
Affiliation(s)
- Seung Min Baik
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul 07985, South Korea
- Department of Surgery, College of Medicine, Graduate School of Korea University, Seoul 02841, South Korea
| | - Yejune Pae
- Department of Surgery, College of Medicine, Graduate School of Korea University, Seoul 02841, South Korea
| | - Jae-Myeong Lee
- Department of Acute Care Surgery, Korea University Anam Hospital, Seoul 02841, South Korea
| |
Collapse
|
45
|
Cai Y, Ren L, Liu X, Li C, Gang X, Wang G. Thyroid storm complicated by corpus callosum infarction in a young patient: A case report and literature review. Medicine (Baltimore) 2022; 101:e30318. [PMID: 36042649 PMCID: PMC9410692 DOI: 10.1097/md.0000000000030318] [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: 11/29/2022] Open
Abstract
RATIONALE Thyroid storm (TS) is a rare life-threatening hypermetabolic thyrotoxicosis with an incidence of 0.57-0.76/100,000. The coexistence of TS and acute cerebral infarction is rare. Previous studies have shown that hyperthyroidism complicated by cerebral infarction mainly occurs in the intracranial basal ganglia; however, there are no reports of corpus callosum infarction. We report a case of TS complicated by cerebral infarction of the corpus callosum at our hospital. PATIENT CONCERNS A 31-year-old male patient with a history of hyperthyroidism was admitted to the hospital because of fatigue, palpitations, fever, and profuse sweating accompanied by a mild decrease in the muscle strength of the left limb. Diagnosis of a TS was confirmed by the laboratory test results. The patient's clinical symptoms gradually improved after treatment. However, his left limb muscle strength progressively decreased, and the bilateral pathological signs were positive at the same time. Magnetic resonance imaging (MRI) of the head revealed acute cerebral infarction of the corpus callosum and pons. DIAGNOSIS The diagnosis was thyroid strom with acute cerebral infarction of the corpus callosum and pons and severe stenosis or occlusion of the basilar artery. INTERVENTIONS The patient was given 300 mg hydrocortisone intravenously per day, propylthiouracil tablets of 200 mg 3 times a day by nasal feeding, and 20 mg propranolol three times a day by nasal feeding. Aspirin and clopidogrel were administered to prevent platelet aggregation, and atorvastatin calcium was administered to lower lipid levels to stabilize plaques. OUTCOMES The patient's left limb muscle strength recovered to grade 4+, and he could walk beside the bed with support. Simultaneously, thyroid function was better than before. LESSONS Careful physical examination should be performed in patients with thyroid storm, and head imaging examination should be improved for the early detection of cerebral infarction.
Collapse
Affiliation(s)
- Yunjia Cai
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Linan Ren
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Xinming Liu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Chen Li
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun 130021, China
| |
Collapse
|
46
|
Park SJ, Kim DJ, Hong YS, Lim SH, Park J. Acute right ventricular failure evoked by trauma induced thyroid storm supported by extracorporeal membrane oxygenation: A case report. Medicine (Baltimore) 2022; 101:e29359. [PMID: 35960049 PMCID: PMC9371557 DOI: 10.1097/md.0000000000029359] [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] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Cardiac arrest due to thyroid storm is a very rare clinical feature with high mortality that presents as multiorgan dysfunction. The mortality rate under this condition is close to 30%, even with appropriate treatment. Most thyroid storms occur in patients with long-standing untreated hyperthyroidism. PATIENT CONCERNS A 67-year-old woman, who had no specific medical history, was admitted with stupor mentality after a pedestrian traffic accident. DIAGNOSIS The patient had a Burch and Wartofsky score of 80, well beyond the criteria for diagnosis of a thyroid storm (>45 points). INTERVENTIONS Venoarterial extracorporeal membrane oxygenation (ECMO) was performed due to persistent unstable vital signs and findings of right ventricular dysfunction after return of spontaneous circulation after cardiopulmonary resuscitation. Circulatory assist with ECMO was performed for 8 days using a beta blocker, steroids, thionamide, and Lugol iodine solution. OUTCOMES Myocardial function and thyroid hormone levels were rapidly normalized. The patient's mental state recovered, and patient was discharged on day 36 maintaining medication. LESSONS Diagnosis of a thyroid storm in patients with multiple trauma is very difficult, because most trauma patients have symptoms of tachycardia, altered mental status, and abdominal pain that appear in thyrotoxic events. However, when unexplained shock without bleeding evidence occurs in patients with multiple trauma, a thyroid function test should be performed to rule out thyroid storm. Moreover, if hyperthyroidism is observed in a trauma patient, even if there is no history of hyperthyroidism, the possibility of a thyroid storm must be considered along with medical support treatment such as ECMO in patient with cardiogenic shock.
Collapse
Affiliation(s)
- Soo Jin Park
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Do Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - You Sun Hong
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang Hyun Lim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jiye Park
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- *Correspondence: Jiye Park, MD, Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164, Worldcup-ro, Yeongtong-gu, Suwon, 16499, Korea (e-mail: )
| |
Collapse
|
47
|
Itagaki T, Miura T, Kasai T, Ikeda U. Symptomatic and severe pulmonary hypertension due to hyperthyroidism. BMJ Case Rep 2022; 15:e251120. [PMID: 35922086 PMCID: PMC9352981 DOI: 10.1136/bcr-2022-251120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/04/2022] Open
Abstract
Hyperthyroidism has been recognised as the cause of secondary pulmonary hypertension (PH). However, several studies have reported that most PH cases due to hyperthyroidism are asymptomatic and not severe. Here, we report the case of a woman in her 30s with symptomatic and severe PH due to hyperthyroidism. She presented with a 2-month history of dyspnoea on exertion, palpitation and lower-extremity oedema. Echocardiography showed severe PH with estimated pulmonary arterial systolic pressure (ePASP) of 62 mm Hg. The diagnostic work-up showed severe PH due to hyperthyroidism. After treatment for hyperthyroidism, improvement of thyroid function contributed to a decrease in ePASP to 30 mm Hg. Similar to the present case, PH due to hyperthyroidism generally improves with the treatment of hyperthyroidism. Therefore, we must not overlook hyperthyroidism as a cause of PH and diagnose and start treatment for PH-causing hyperthyroidism at an early stage.
Collapse
Affiliation(s)
- Tadashi Itagaki
- Department of Cardiology, Nagano Municipal Hospital, Tomitake, Nagano, Japan
| | - Takashi Miura
- Department of Cardiology, Nagano Municipal Hospital, Tomitake, Nagano, Japan
- Department of Internal Medicine and Cardiology, Miura Heart Clinic, Minamitakada, Nagano, Japan
| | - Toshio Kasai
- Department of Cardiology, Nagano Municipal Hospital, Tomitake, Nagano, Japan
| | - Uichi Ikeda
- Department of Cardiology, Nagano Municipal Hospital, Tomitake, Nagano, Japan
| |
Collapse
|
48
|
De Almeida R, McCalmon S, Cabandugama PK. Clinical Review and Update on the Management of Thyroid Storm. MISSOURI MEDICINE 2022; 119:366-371. [PMID: 36118802 PMCID: PMC9462913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves' disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis. The purpose of this article is a clinical review of the various treatments and methodologies to achieve a euthyroid state in patients with thyroid storm prior to definitive therapy.
Collapse
Affiliation(s)
- Reuben De Almeida
- Internal Medicine Resident, University of Missouri-Kansas City-School of Medicine (UMKC-SOM), Kansas City, Missouri
| | - Sean McCalmon
- Endocrinology Fellow at UMKC-SOM, Kansas City, Missouri
| | - Peminda K Cabandugama
- Assistant Professor of Medicine and Faculty Member of the Endocrinology Fellowship Program at the UMKC-SOM, Kansas City, Missouri
| |
Collapse
|
49
|
Uchihara M, Ehara J, Iwanami K, Kitamura K, Suzuki T, Ishizuka N, Yamada T, Hiraoka E. Chylous Ascites Due to Hyperthyroidism and Heart Failure. Intern Med 2022; 61:1995-1998. [PMID: 34897150 PMCID: PMC9334248 DOI: 10.2169/internalmedicine.7873-21] [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: 12/02/2022] Open
Abstract
Chylous ascites (CA) is the accumulation of fluid with a high triglyceride content in the peritoneal cavity. Only two cases in the literature have reported CA with hyperthyroidism. A 28-year-old previously healthy woman presented with gradual-onset abdominal swelling, exertional dyspnea, and diarrhea. Hyperthyroidism and heart failure were diagnosed using laboratory investigation and echocardiography. Ultrasonography revealed a large amount of ascites. The ascitic fluid was milky with elevated triglyceride levels. Treatment with anti-thyroid therapy and diuretics improved all symptoms, and the free triiodothyronine (T3) level normalized after five days. Hyperthyroidism and heart failure should be considered as reversible causes of CA.
Collapse
Affiliation(s)
- Masaki Uchihara
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Professional Development, Tokyo Medical and Dental University Hospital, Japan
| | - Jun Ehara
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Keiichi Iwanami
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Rheumatology, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Koichi Kitamura
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Toshihiko Suzuki
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Noriyoshi Ishizuka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Toru Yamada
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| |
Collapse
|
50
|
Hamed M, Palumbo S, Mendha T. Severe Cardiovascular Effects of Prolonged Untreated Hyperthyroidism Manifesting As Thyroid Storm. Cureus 2022; 14:e26289. [PMID: 35898385 PMCID: PMC9308973 DOI: 10.7759/cureus.26289] [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] [Received: 04/23/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
A thyroid storm is a rare but life-threatening manifestation of thyrotoxicosis. It still remains a diagnostic challenge as there are no specific laboratory investigations or universally accepted criteria for diagnosing thyroid storms. Diagnosis is mainly based on clinical findings, evidence of hyperthyroidism, and life-threatening symptoms. A thyroid storm has a high risk of mortality mostly due to multi-organ failure and heart failure. Cardiovascular manifestations are the most common presentation of hyperthyroidism; cardiac involvement also has the potential to be the most serious complication. Management of cardiovascular manifestations should be managed aggressively to prevent long-term myocardial damage. A high index of suspicion should be maintained in young adults presenting with heart failure and arrhythmia. We present a case of potentially life-threatening cardiovascular effects of thyroid storm and management in the ICU.
Collapse
|