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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.
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Affiliation(s)
| | | | | | - Guido Alarcon
- Pediatric Endocrinology, Baylor College of Medicine, Houston, TX, USA
| | - Alejandro Diaz
- Pediatric Endocrinology, Nicklaus Children's Hospital, Miami, FL, USA
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Perry LD, Hogg SL, Bowdin S, Ambegaonkar G, Parker AP. Fifteen-minute consultation: The efficient investigation of infantile and childhood epileptic encephalopathies in the era of modern genomics. Arch Dis Child Educ Pract Ed 2022; 107:80-87. [PMID: 33414255 DOI: 10.1136/archdischild-2020-320606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/05/2020] [Accepted: 12/09/2020] [Indexed: 11/03/2022]
Abstract
The investigation of children presenting with infantile and childhood epileptic encephalopathies (ICEE) is challenging due to diverse aetiologies, overlapping phenotypes and the relatively low diagnostic yield of MRI, electroencephalography (EEG) and biochemical investigations. Careful history and thorough examination remain essential as these may identify an acquired cause or indicate more targeted investigation for a genetic disorder. Whole exome sequencing (WES) with analysis of a panel of candidate epilepsy genes has increased the diagnostic yield. Whole genome sequencing (WGS), particularly as a trio with both parents' DNA, is likely to supersede WES. Modern genomic investigation impacts on the timing and necessity of other testing. We propose a structured approach for children presenting with ICEE where there is diagnostic uncertainty, emphasising the importance of WGS or, if unavailable, WES early in the investigative process. We note the importance of expert review of all investigations, including radiology, neurophysiology and biochemistry, to confirm the technique used was appropriate as well as the results. It is essential to counsel families on the risks associated with the procedures, the yield of the procedures, findings that are difficult to interpret and implication of 'negative' results. Where children remain without a diagnosis despite comprehensive investigation, we note the importance of ongoing multidisciplinary care.
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Affiliation(s)
- Luke Daniel Perry
- Developmental Neurosciences, University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Sarah Louise Hogg
- Biochemical Genetics Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sarah Bowdin
- Department of Clinical Genetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gautam Ambegaonkar
- Paediatric Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alasdair Pj Parker
- Paediatric Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Bridwell RE, Figlewicz MR, Birdsong S, Goss S, Belcher CN. Pediatric volvulus induced thyroid storm: A case report. Am J Emerg Med 2021; 49:439.e3-439.e5. [PMID: 33926769 DOI: 10.1016/j.ajem.2021.04.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022] Open
Abstract
Thyroid storm is an unusually rare but life-threatening pediatric occurrence, carrying significant mortality. Skewed towards the adolescent population, thyroid decompensation occurs due to inciting factors ranging from infection, trauma, surgery, burns, medications, direct thyroid trauma, and rarely volvulus. Emergent care focuses on both reversing the inciting event as well as quelling the metabolic hyperactivity associated with thyroid storm. In review of the available literature, this case is the first to date of thyroid storm secondary to malrotation with midgut volvulus in a previously euthyroid adolescent patient.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Matthew R Figlewicz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Sara Birdsong
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Sarah Goss
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Christopher N Belcher
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
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Graulich B, Irizarry K, Orlowski C, Wittlieb-Weber CA, Weber DR. Severe multisystem organ dysfunction in an adolescent with simultaneous presentation of Addison's and Graves' disease. J Pediatr Endocrinol Metab 2021; 34:411-415. [PMID: 33675209 PMCID: PMC8366912 DOI: 10.1515/jpem-2020-0438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To report an unusual case of simultaneous presentation of Addison's and Graves' disease in an adolescent female previously diagnosed with type 1 diabetes (T1D) and Hashimoto's. CASE PRESENTATION A 15-year-old female with T1D and hypothyroidism presented to the emergency department with altered mental state, fever, and left arm weakness for one day. Clinical work-up revealed coexistent new-onset adrenal insufficiency and hyperthyroidism. Her clinical course was complicated by severe, life-threating multisystem organ dysfunction including neurologic deficits, acute kidney injury, and fluid overload. Thyroidectomy was ultimately performed in the setting of persistent signs of adrenal crises and resulted in rapid clinical improvement. CONCLUSIONS Endocrinopathy should be included in the differential diagnosis of altered mental status. This case additionally illustrates the challenges of managing adrenal insufficiency in the setting of hyperthyroidism and supports the use of thyroidectomy in this situation.
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Affiliation(s)
- Bethany Graulich
- Department of Pediatrics, Golisano Children’s Hospital, University of Rochester Medical Center, Rochester NY, USA
| | - Krystal Irizarry
- Department of Pediatrics, Golisano Children’s Hospital, University of Rochester Medical Center, Rochester NY, USA
| | - Craig Orlowski
- Department of Pediatrics, Golisano Children’s Hospital, University of Rochester Medical Center, Rochester NY, USA
| | - Carol A. Wittlieb-Weber
- Department of Pediatrics, Golisano Children’s Hospital, University of Rochester Medical Center, Rochester NY, USA
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Chauhan JC, Frizzola M, McMahon K, Perry S, Hertzog JH. Thyroid storm with encephalopathy and cardiovascular symptoms refractory to medical management in an adolescent. Int J Crit Illn Inj Sci 2020; 10:38-41. [PMID: 32322553 PMCID: PMC7170342 DOI: 10.4103/ijciis.ijciis_58_19] [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: 08/26/2019] [Revised: 10/24/2019] [Accepted: 12/02/2019] [Indexed: 11/04/2022] Open
Abstract
Thyroid storm (TS) is rare in pediatrics, most cases reported in literature responded well to medical therapy. We report the case of an adolescent female presented with TS refractory to anti-thyroid medical management. She had refractory hypertension, tachycardia, and progressive encephalopathy despite aggressive medical management. She underwent subtotal thyroidectomy after 2 weeks of failed medical management with a complete resolution of symptoms within days of surgery. We also learned sodium nitroprusside with its direct vasodilatory effect on conduit vessels, verapamil with its rate control properties, and labetalol with its dual sympathetic blockage property were beneficial in the management of this patient.
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Affiliation(s)
- Jigar C Chauhan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Meg Frizzola
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kimberly McMahon
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sarah Perry
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - James H Hertzog
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Ladd JM, Sabsabi B, von Oettingen JE. Thyroid Storm in a Toddler Presenting as a Febrile Seizure. Pediatrics 2020; 145:peds.2019-1920. [PMID: 31980544 DOI: 10.1542/peds.2019-1920] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 11/24/2022] Open
Abstract
Although simple febrile seizures are relatively common and benign in toddlers, it is important to rule out any underlying critical disease that necessitates further intervention and treatment. Thyroid storm, the extreme manifestation of hyperthyroidism, is relatively rare and not often considered in the differential diagnosis of a febrile seizure despite its high mortality rate. Here, we report 1 of the youngest patients with thyroid storm, who initially presented with a febrile seizure. After reevaluation, the 2-year-9-month-old patient was discovered to have thyromegaly, which led to recognition that her persistent tachycardia and widened pulse pressure were likely signs of thyrotoxicosis. Laboratory results were consistent with primary hyperthyroidism due to Graves' disease. Thyroid storm was then diagnosed on the basis of clinical features including gastrointestinal and central nervous system disturbances. Treatment with methimazole, propranolol, hydrocortisone, and Lugol's iodine solution was used. This medication regimen was safe and effective with restoration of a euthyroid state after 2 months and no recurrence of seizures. Improved awareness of hyperthyroidism and thyroid storm can lead to prompt diagnosis and treatment of this endocrine emergency, thus reducing mortality and morbidity. Pediatricians should consider this diagnosis in children with febrile seizures and suggestive vital signs and physical examination findings.
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Affiliation(s)
- Jennifer M Ladd
- Division of Pediatric Endocrinology, Department of Pediatrics and
| | - Bayane Sabsabi
- Division of General Pediatrics, Department of Pediatrics, McGill University, Montreal, Canada; and
| | - Julia E von Oettingen
- Division of Pediatric Endocrinology, Department of Pediatrics and.,The Research Institute of the McGill University Health Centre, Montreal, Canada
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Creo AL, Cannon BC, Pittock ST. Thyroid storm after choking. J Pediatr Endocrinol Metab 2018; 31:933-936. [PMID: 29935115 DOI: 10.1515/jpem-2018-0072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/01/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND A thyroid storm (TS) is a rare, but life-threatening condition in hyperthyroid patients. Mortality in adult TS patients may be as high as 10%. Typically, a trigger precipitates the storm in hyperthyroid patients. CASE PRESENTATION We report the case of an adolescent girl with untreated hyperthyroidism who developed fulminant TS after a significant choking episode. Initially, she was found to have neck swelling and tachycardia leading providers to suspect infection. She deteriorated after a CAT Scan (CT) was performed with iodine contrast, potentially worsening storm symptoms. Here, we describe the case, the treatment strategy and propose a treatment modification for pediatric patients. CONCLUSIONS While many children are found to have minor abnormalities in thyroid studies, this case highlights the critical importance of prompt medical attention for any child with significantly elevated free thyroxine (FT4) levels as morbidity can occur when left untreated.
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Affiliation(s)
- Ana L Creo
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Bryan C Cannon
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Siobhan T Pittock
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
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Bonfield A, Shenoy S. Thyrotoxic crisis as an acute clinical presentation in a child. BMJ Case Rep 2018; 2018:bcr-2017-222850. [DOI: 10.1136/bcr-2017-222850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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A Case of Thyroid Storm Associated with Cardiomyopathy and Poststreptococcal Glomerulonephritis. Case Rep Pediatr 2016; 2016:7192359. [PMID: 27867675 PMCID: PMC5102721 DOI: 10.1155/2016/7192359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/21/2016] [Indexed: 11/18/2022] Open
Abstract
Thyroid storm has a high mortality rate and is often associated with a precipitating factor such as intercurrent illness or infection. It is rare in pediatric patients. Cardiac disease in hyperthyroidism mostly manifests itself as tachycardia but more serious cardiac findings have also been described. A 5-year-old male with recent strep throat infection presented with dilated cardiomyopathy, hematuria, and symptoms and lab findings consistent with severe hyperthyroidism. He was diagnosed with thyroid storm secondary to concurrent Graves' disease and poststreptococcal glomerulonephritis (PSGN). After starting the treatment with methimazole and a beta-blocker, his cardiac disease gradually improved and the PSGN resolved over time. There are no specific pediatric criteria for thyroid storm. Adult criteria can be difficult to apply to pediatric cases. Criteria for diagnosis of thyroid storm are less clear for pediatric patients. Dilated cardiomyopathy is a rare cardiac manifestation of hyperthyroidism. PSGN is due to glomerular immune complexes and can complicate group A strep infection. Providers should be aware of cardiac disease as a complication of hyperthyroidism. PSGN should not mechanistically be related to hyperthyroidism but can precipitate the signs of thyroid storm such as hypertension. This association has not been previously reported in the literature.
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Intraoperative Diagnosis and Treatment of Thyroid Storm in a 15-Year-Old Male. ACTA ACUST UNITED AC 2014; 3:107-9. [DOI: 10.1213/xaa.0000000000000074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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