Serotonin syndrome: A rare yet crucial diagnosis

ABSTRACT

Serotonin syndrome is a rare, life-threatening toxidrome caused by serotonergic agents. This syndrome classically presents with a combination of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. However, diagnosing the condition is difficult because of its variable symptoms at presentation. As a result, serotonin syndrome often is underreported, making it harder to understand, recognize, and treat. Patients with this condition may present to primary or urgent care or an ED, and may become acutely symptomatic during an inpatient admission. Clinicians must be able to identify at-risk patients and intervene to prevent potentially lethal complications.

Endocrine Emergencies

Endocrine emergencies encompass a group of conditions that occur when hormonal deficiency or excess results in acute presentation. If these endocrine disorders are not rapidly identified or if specific treatment is delayed, significant complications or even death may occur. This article outlines the basics of endocrine emergencies involving the thyroid, parathyroid, pituitary, pancreas, and adrenal glands. It discusses various causative factors, diagnostic approaches, and treatment modalities, emphasizing the significance of preventive measures. This article is aimed at guiding health care professionals, and this overview seeks to enhance understanding and improve patient outcomes in managing endocrine emergencies.

Thyroid storm with acute liver failure and disseminated intravascular coagulation- lessons in diagnosis and treatment

Thyroid storm is a medical emergency with a high mortality rate. Acute liver failure (ALF) and disseminated intravascular coagulation (DIC) are rarely reported with thyroid storm, and their occurrence is unrelated to the degree of free circulating thyroxine.We present the case of a 41-year-old Sri Lankan female, with a fatal case of thyroid storm. She initially presented with palpitations and heat intolerance, and subsequently developed acute liver failure with hepatic encephalopathy and coagulopathy. There was hypoglycemia and resistant lactic acidosis consequent to the liver failure. The clinical course progressed to DIC and she eventually succumbed to the illness. Treatment comprised the standard management of thyroid storm.This case report highlights the importance of bearing ALF and DIC in mind as complications of thyroid storm, outlines their pathophysiology, and uses pathophysiological mechanisms to justify, evolving extracorporeal therapeutic strategies for resistant cases.

A Lower Prevalence of Central Nervous System and Higher Prevalence of Cardiac Symptoms Characterises Indian Patients with Thyrotoxic Storm: A Retrospective Analysis

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.

Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery

BACKGROUND

Total thyroidectomy for hyperthyroidism is typically followed by overnight admission to monitor for complications including thyrotoxicosis. Outpatient thyroid surgery is increasingly common, but its safety in patients with hyperthyroidism has not been well studied.

METHODS

This retrospective study reviewed 183 patients with hyperthyroidism who underwent total thyroidectomy from 2015 to 2022 at one urban, academic center. The main outcomes were rates of thyroid storm, surgical complications, and 30-day ED visits and readmissions.

RESULTS

Among 183 patients with hyperthyroidism (mean age, 45 ± 14.5 years; 82.5% female), there were no cases of thyroid storm and complications included recurrent laryngeal nerve (RLN) palsy (7.0%), symptomatic hypocalcemia (4.4%), and hematoma (1.6%). ED visits were present in 1.1% and no patients were readmitted.

CONCLUSION

Total thyroidectomy was not associated with thyroid storm and <6% of patients required inpatient management. Ambulatory total thyroidectomy for hyperthyroidism warrants further consideration through identification of predictive factors for postoperative complications.

A rare case of bilateral frontal lobe lesions due to thyroid storm

Thyroid storm is a rare but well-known life-threatening complication that occurs due to acute exacerbation of thyrotoxicosis with the increased levels of circulating thyroid hormones. Reports of metabolic encephalopathy associated with thyroid storm are scarce. We describe the case of a 23-year-old male patient with no previous history of abnormal thyroid function who had consumed excessive amounts of alcohol before disease onset. The patient was found unconscious and febrile on a roadside by a passerby and was admitted to our hospital's emergency department. His primary clinical presentation included hyperthermia (40.8 °C), nodal tachycardia (180 beats/min), seizures, coma, and hypoglycemia (2.18 mmol/L). The hypoglycemia was quickly corrected after admission, but his level of consciousness showed no improvement. With aggressive screening, the patient was found to have severe thyroid dysfunction (T3 = 6.67 nmol/L, T4 = 252.00 nmol/L, free T3 = 29.20 pmol/L, free T4 = 65.30 pmol/L, and TSH = 0.001 μIU/mL). After medical treatment, plasmapheresis, hemofiltration, and hemoperfusion, the patient showed substantial improvement in thyroid hormone levels and stabilization of vital signs, but the impaired consciousness and seizures persisted. Multiple computed tomography scans revealed brain abnormalities. Magnetic resonance imaging performed after tracheal extubation revealed bilateral frontal lobe lesions. We reported a case of metabolic encephalopathy in a patient with life-threatening thyroid storm and bilateral frontal lobe lesions. Hypoglycemia may have been involved in the development of encephalopathy in our patient. Health care providers should consider thyroid storm in the differential diagnosis of hyperthermia, seizures, and coma. Early plasmapheresis, hemofiltration, and hemoperfusion can lower T4 levels and improve prognosis in patients with thyroid storm and encephalopathy.

Untreated Graves' Disease Complicated by Thyroid Storm and High-Output Cardiac Failure: A Case Report

Thyroid storm is a rare yet critical complication of uncontrolled thyrotoxicosis, posing significant challenges in clinical management. We present the case of a 65-year-old African-American female with a medical history significant for untreated Graves' disease, hypertension, and diverticulosis, who presented with escalating abdominal pain, accompanied by nausea, vomiting, diarrhea, and chest discomfort. Upon admission, she exhibited atrial fibrillation with rapid ventricular response (RVR) and newly diagnosed high-output cardiac failure. Diagnosis of thyroid storm was confirmed through comprehensive laboratory assessments and clinical evaluation. Treatment with beta-blockers, anti-thyroid medications, and corticosteroids facilitated stabilization of her condition. This case report highlights the importance of early identification and intervention in thyroid storm to avert potential morbidity and mortality.

Total Thyroidectomy while on Extracorporeal Membrane Oxygenation for Thyroid Storm

Thyroid storm is an acute life-threatening condition of hyperthyroidism that can present with cardiac failure, requiring extracorporeal membrane oxygenation (ECMO). We present the first case reported of total thyroidectomy successfully performed while on ECMO for thyroid storm in a 32-year-old male. This case highlights the challenges of managing refractory thyroid storm with multi-organ failure. We demonstrate that total thyroidectomy may still be safely performed while on ECMO for thyroid storm, if steps are taken to optimise the patient perioperatively, with careful surgical and anaesthesia planning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04430-9.

Diagnostic criteria and scoring systems for thyroid storm: An evaluation of their utility - comparative review

A thyroid storm is a life-threatening endocrine emergency characterized by severe hyperthyroidism and many systemic manifestations. Prompt recognition and treatment are essential for patient survival. This study evaluates the utility of existing diagnostic criteria and scoring systems for thyroid storm. A comprehensive literature review encompassed articles published up to December 2023. Various diagnostic criteria and scoring systems, such as the Burch-Wartofsky Point Scale and the Japanese Thyroid Association criteria, were critically assessed based on their sensitivity, specificity, and clinical applicability. Our findings reveal that existing diagnostic criteria and scoring systems, although valuable tools, exhibit limitations. They may lack sensitivity in identifying milder cases of thyroid storm or fail to differentiate it from other critical conditions. Furthermore, some criteria rely heavily on subjective clinical Judgment, which can vary among healthcare providers. Future research should focus on refining existing criteria and developing more objective and universally applicable diagnostic tools to address these limitations. Incorporating advanced laboratory markers and modern imaging techniques may enhance diagnostic accuracy. Additionally, a standardized scoring system approach could improve clinical practice consistency. In conclusion, while current diagnostic criteria and scoring systems provide a foundation for identifying thyroid storm, their utility has shortcomings. Advancements in diagnostic methods and a collaborative effort to establish standardized criteria are imperative to enhance the accuracy and reliability of thyroid storm diagnosis, ultimately improving patient outcomes.

Trauma-related thyroid storm in adolescents: A case report

Background

Because of a scant report, it is little known that thyroid storms can occur after trauma, even in adolescence. Significantly, this increases the risk of delaying diagnosis resulting in life-threatening.

Case Presentation

A 13-year-old girl was admitted to the emergency department after a traffic accident. Despite receiving comprehensive trauma care, the patient developed hyperthermia and tachycardia that did not respond to temperature management therapy. On the 10th day of her admission, she was diagnosed with a thyroid storm. Treatment for thyroid storm was initiated; thereby, her condition was totally improved.

Conclusion

We experienced a case of an adolescent girl, who developed a thyroid storm during the treatment of trauma and could save her life. Clinicians should consider thyroid storm in post-traumatic hyperthermia and tachycardia patients, even in children.

Therapeutic Plasma Exchange in Refractory Atrial Fibrillation Secondary to a Thyroid Storm

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.

Thyroid storm caused by metastatic papillary thyroid carcinoma tissue after total thyroidectomy: a case report

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.

The Use of Plasmapheresis in a Severe Case of Amiodarone-Induced Thyrotoxicosis

Amiodarone-induced thyrotoxicosis (AIT) can be difficult to treat since amiodarone's long half-life leads to a persistent effect on thyroid function. We present a case of a 74-year-old male with severe AIT who presented with altered mentation and ultimately required intubation and intensive care for management of thyroid storm. Standard medical therapy for treatment of thyroid storm was initiated immediately, but the patient remained unresponsive with worsening biochemical parameters with increasing total T3 levels and sustained elevated levels of free T4 after 5 days of medical management. Due to the lack of a clinical and biochemical response to conventional medical therapy, the patient was started on plasmapheresis and underwent a total of 7 cycles of plasmapheresis over a period of 10 days. He significantly improved with plasmapheresis and was successfully bridged to a total thyroidectomy, which was completed without complications.

Thyrotoxicosis

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.

Data Analysis and Systematic Scoping Review on the Pathogenesis and Modalities of Treatment of Thyroid Storm Complicated with Myocardial Involvement and Shock

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.

Risk factors for cardiogenic shock in thyroid storm: a retrospective and case-series study

Aim: Thyroid storm (TS) occurs in 10% of thyrotoxicosis patients and 1% of TS patients experience cardiogenic shock (CS), which is associated with poor prognosis. Methods: This is a single institution, retrospective study in which 56 patients with TS were evaluated. Results: BMI (p = 0.002), history of heart failure (OR 8.33 [1.91, 36.28]; p = 0.004), pro-BNP elevation (p = 0.04), chest x-ray showing interstitial edema (OR 3.33 [1.48, 7.52]; p = 0.01) and Burch-Wartofsky score (62.5 vs 40; p = 0.004) showed association with CS. CS patients had increased length of stay (16.5 vs 4 days; p = 0.01) and higher in-hospital mortality (OR 24.5 [2.90, 207.29]; p < 0.001). Conclusion: These risk factors are useful to risk stratify TS patients on admission, institute therapy in a timely manner and decrease mortality.

Levothyroxine Prescription Error: A Case Report

Levothyroxine (LT) is the synthetic form of thyroxine (T4), a thyroid hormone analog used to treat hypothyroidism. LT overdose rarely results in severely poor outcomes. General guidelines for treating exogenous thyrotoxicosis depend on the severity of symptoms. There is no standardized protocol; however, drug discontinuation, beta-blockers (specifically propranolol), and cholestyramine effectively manage overdose when needed, with most cases resolving independently without medical intervention.  Here, we present the case of a 26-year-old female with a history of supraventricular tachycardia, anxiety, depression, and Hashimoto thyroiditis who was accidentally overprescribed LT (300 mcg for one and a half months) that resulted in symptoms of lethargy, tremors, body temperature dysregulation, orthostatic hypotension, and diarrhea. This case, with limited evidence, suggests that excessive LT exacerbated the patient's underlying psychiatric symptoms, encouraging suicidal ideation.

High risk and low prevalence diseases: Thyroid storm

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.

Pneumonia-Induced Thyroid Crisis With Thyrotoxicosis Exacerbation: De Novo Graves' Disease Presentation on a Cornelia de Lange Syndrome (CdLS)

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.

Long-term survival in a dog with probable thyroid storm

Key Clinical Message

Thyroid storm is a rare, life-threatening endocrine emergency that may occur in dogs. With rapid identification and early aggressive therapy, long-term survival is possible.

Abstract

The aim of this paper was to describe the successful emergency management and long-term survival of a dog with probable thyroid storm. We present proposed guidelines for the characterization of thyroid storm in dogs, and treatment considerations as utilized for this patient. A 6-year-old female spayed German Shepherd Dog was presented to a multispecialty center for radiation planning and treatment of a previously diagnosed nonresectable functional thyroid carcinoma. Recovering from anesthesia, the patient developed clinical features that would qualify as thyroid storm using human metrics. The patient improved with aggressive treatment of thyroid storm, extrapolating from human and feline recommendations. This is the first known report of long-term survival in a canine with suspected thyroid storm. The crisis was effectively identified and emergently treated.

The Thyroid Forecast: A Case of a Thyroid Storm Diagnosed Under Unforeseen Circumstances

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.

Thyroid storm in pediatrics: a systematic review

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.

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

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.

Mechanisms and Management of Thyroid Disease and Atrial Fibrillation: Impact of Atrial Electrical Remodeling and Cardiac Fibrosis

Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with increased cardiovascular morbidity and mortality. The pathophysiology of AF is characterized by electrical and structural remodeling occurring in the atrial myocardium. As a source of production of various hormones such as angiotensin-2, calcitonin, and atrial natriuretic peptide, the atria are a target for endocrine regulation. Studies have shown that disorders associated with endocrine dysregulation are potential underlying causes of AF. The thyroid gland is an endocrine organ that secretes three hormones: triiodothyronine (T3), thyroxine (T4) and calcitonin. Thyroid dysregulation affects the cardiovascular system. Although there is a well-established relationship between thyroid disease (especially hyperthyroidism) and AF, the underlying biochemical mechanisms leading to atrial fibrosis and atrial arrhythmias are poorly understood in thyrotoxicosis. Various animal models and cellular studies demonstrated that thyroid hormones are involved in promoting AF substrate. This review explores the recent clinical and experimental evidence of the association between thyroid disease and AF. We highlight the current knowledge on the potential mechanisms underlying the pathophysiological impact of thyroid hormones T3 and T4 dysregulation, in the development of the atrial arrhythmogenic substrate. Finally, we review the available therapeutic strategies to treat AF in the context of thyroid disease.

Notes for the general paediatrician: managing thyrotoxicosis in children and young people

Thyrotoxicosis due to hyperthyroidism is a serious disorder in childhood often presenting to general paediatricians with a range of clinical manifestations. The commonest cause is Graves' disease, an autoimmune disorder resulting from thyrotropin receptor stimulation by autoantibodies. Early recognition and accurate interpretation of investigations are essential to achieve and maintain a euthyroid state. This will not only optimise growth, development and transition from childhood to young adult life but also avoid the potentially severe and life-threatening complications of acute thyrotoxicosis. In this review, we have focussed on the general paediatrician's perspective of the presentation and management of thyrotoxicosis and the need to network with specialist paediatric endocrine centres to optimise patient care. We have discussed nuances of therapy, side effects and long-term outcomes, while recognising that limited remission rates in this age group often necessitate more definitive management. While carbimazole is usually used as first-line medical therapy, we have provided useful information to guide paediatricians in the discussion of individualised safe and effective treatment plans for both short-term and long-term management.

Cardiovascular Collapse Secondary to Beta-Blocker Administration in a Setting of Coexisting Thyroid Storm and Atrial Fibrillation: A Case Report

A thyroid storm is a rare endocrinological emergency caused by severe hyperthyroidism. Reducing circulating levels of free T3 in blood and beta-adrenergic inhibition are the basis of medical treatment for thyroid storms. Propranolol, due to its additional effect of preventing the peripheral conversion of dormant T4 to active form T3, is the chosen drug for blockade in hyperthyroidism and thyroid storm. We describe a rare clinical case of cardiovascular collapse following propranolol administration in a setting of thyroid storm. The patient presented with symptoms of dyspnea and palpitations and had an ejection fraction of 10%. He was started on a calcium channel blocker (diltiazem). Further investigations revealed that the patient also had a thyroid storm and was immediately shifted to methimazole and propranolol. However, following the administration of a beta-blocker, the patient developed circulatory failure as a result of cardiac arrest, necessitating the use of vasopressors and inotropes. This implores the need for further investigations and treatment regimens for cardiovascular conditions, especially atrial fibrillation arising in thyrotoxicosis, as there are no solid treatment guides in the literature to the best of our knowledge.

Perioperative management of the thyrotoxic patients: A systematic review

Background

Thyrotoxicosis is a clinical syndrome produced by a multitude of disorders. Thyrotoxicosis is a serious medical condition that, if left untreated, can lead to a fatal illness. This review of recent evidences give additional input for perioperative management of thyrotoxic patients.

Methods

The literatures were found with Boolean operators in the form of thyrotoxicosis AND anesthesia, antithyroid medications AND perioperative optimization AND beta blockers OR calcium channel blockers in electronic data base sources such as the Cochrane library, PubMed, and Google scholar. This review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

Conclusions

and recommendations: Before surgery and anesthesia, manifestation of thyrotoxicosis including palpitation, irritability etc should be ruled out.

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Thyrotoxicosis is a clinical syndrome produced by a multitude of disorders.

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Hyperthyroidism is a prevalent clinical condition that raises the risk of complications.

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Surgery and anesthesia should be postponed in elective thyrotoxicosis patients.

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Patients with thyrotoxicosis symptoms and elevated thyroid function tests should be optimized for 12–18 months.

Perioperative Management for Non-Thyroidal Surgery in Thyroid Dysfunction

Thyroid hormone exerts effects across all organ systems. Hence, patients with thyroid dysfunction are at a risk of numerous complications. The stresses encountered during the perioperative period may exacerbate underlying thyroid disorders, potentially precipitating decompensation, and even death. Thus, it is of the utmost importance for the clinician to comprehend the mechanisms by which thyroid disease may complicate surgery and postoperative recovery and to optimize the status of thyrotoxic and hypothyroid patients. This article describes the adverse effects of thyroid dysfunction in patients undergoing nonthyroid surgery and recommends treatment approaches aimed at appropriate build-up to decrease perioperative risk.

Thyroid storm complicated by corpus callosum infarction in a young patient: A case report and literature review

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.

Identification of a Thyroid Hormone Binding Site in Hsp90 with Implications for Its Interaction with Thyroid Hormone Receptor Beta

While many proteins are known clients of heat shock protein 90 (Hsp90), it is unclear whether the transcription factor, thyroid hormone receptor beta (TRb), interacts with Hsp90 to control hormonal perception and signaling. Higher Hsp90 expression in mouse fibroblasts was elicited by the addition of triiodothyronine (T3). T3 bound to Hsp90 and enhanced adenosine triphosphate (ATP) binding of Hsp90 due to a specific binding site for T3, as identified by molecular docking experiments. The binding of TRb to Hsp90 was prevented by T3 or by the thyroid mimetic sobetirome. Purified recombinant TRb trapped Hsp90 from cell lysate or purified Hsp90 in pull-down experiments. The affinity of Hsp90 for TRb was 124 nM. Furthermore, T3 induced the release of bound TRb from Hsp90, which was shown by streptavidin-conjugated quantum dot (SAv-QD) masking assay. The data indicate that the T3 interaction with TRb and Hsp90 may be an amplifier of the cellular stress response by blocking Hsp90 activity.

Endocrine Emergencies in the Medical Intensive Care Unit

Endocrine emergencies are underdiagnosed and often overlooked amid the management of severe multisystem pathologies in critically ill patients in the medical intensive care unit (ICU). In an appropriate clinical scenario, a low threshold of suspicion should be kept to investigate for various life-threatening, yet completely treatable, endocrinopathies. Prompt identification and treatment of endocrine emergencies such as diabetic ketoacidosis, myxedema coma, thyroid storm, and/or adrenal insufficiency leads to fewer complications, shorter ICU and hospital stay, and improved survival. This review article entails common endocrine emergencies encountered in the ICU and addresses their epidemiology, pathophysiology, clinical presentation and management.

Triiodothyronine Acts as a Smart Influencer on Hsp90 via a Triiodothyronine Binding Site

Microarray-based experiments revealed that thyroid hormone triiodothyronine (T3) enhanced the binding of Cy5-labeled ATP on heat shock protein 90 (Hsp90). By molecular docking experiments with T3 on Hsp90, we identified a T3 binding site (TBS) near the ATP binding site on Hsp90. A synthetic peptide encoding HHHHHHRIKEIVKKHSQFIGYPITLFVEKE derived from the TBS on Hsp90 showed, in MST experiments, the binding of T3 at an EC₅₀ of 50 μM. The binding motif can influence the activity of Hsp90 by hindering ATP accessibility or the release of ADP.

Thyrotoxicosis-Related Left Main Coronary Artery Spasm Presenting As Acute Coronary Syndrome

Thyrotoxicosis can cause acute chest pain without ST changes in EKG due to coronary artery spasm. Its diagnosis can be particularly challenging as the symptoms may mimic acute coronary syndrome. The diagnosis of coronary artery spasm is confirmed by coronary angiography. The use of intracoronary nitroglycerin can relieve spasms and reveal the true extent of coronary artery disease. We present a case of a perimenopausal woman with newly diagnosed hyperthyroidism who presented with chest pain. Coronary angiography showed spasm of the left anterior descending artery which was relieved by intracoronary nitroglycerin. 

Hyperthyroidism is associated with a spectrum of cardiovascular manifestations ranging from relatively benign palpitations to cardiac arrest. Rarely, it has been associated with episodic angina which indicates myocardial ischemia secondary to coronary artery spasm. Thyrotoxicosis-induced coronary artery spasm is a rare condition. Coronary artery spasm might masquerade as acute coronary syndrome, and coronary angiography is usually necessary to rule out myocardial infarction. In patients with risk factors for developing thyrotoxicosis-induced coronary artery spasm, any stenosis found on coronary angiography must not be assumed to be coronary artery disease only, and the possibility of coronary artery spasm must be explored. Our case emphasizes the use of intraprocedural nitroglycerin in these patients, which can relieve the spasm and reveal the true extent of coronary artery disease. Restoration of euthyroidism is the cornerstone of management and abates the need for long-term coronary vasodilator medications. Early diagnosis and optimal management have a favorable prognosis in these patients. 

Supraventricular Tachycardia: An Atypical Presentation of Thyroid Storm

Thyroid storm (or thyrotoxic crisis) is commonly defined as a life-threatening condition caused by the exaggeration of the clinical manifestations of thyrotoxicosis. Supraventricular tachycardia (SVT) is an atypical precipitating symptom of thyrotoxicosis that clinicians should be aware of. An empirically derived scoring system known as the Burch-Wartofsky Point Scale (BWPS) has been used by clinicians since the early 1990s. The BWPS considers an array of precipitating factors and the severity of symptoms of multiple organ decompensation. In recent years, there has been an increasing correlation between SARS-CoV-2 and thyroid pathologies. We present a case of an unresponsive elderly male with a recent coronavirus disease 2019 (COVID-19) infection presenting with SVT and a BWPS score of 45, highly indicative of a thyroid storm.

Changes in TSH, T4, T3 and Thyroglobulin Levels throughout Total Thyroidectomy

Introduction: To assess the impact of total thyroidectomy on thyroid function. Methods: Monocentric observational prospective study. Patients who benefited from a total thyroidectomy in the Department of Otolaryngology-Head and Neck Surgery between September 2017 and July 2019 were included. Three blood samples were taken from each patient during the perioperative period: preoperatively (T₀), intraoperatively (T₁), and postoperatively (T₂). Changes in TSH, T4, T3, and thyroglobulin levels were evaluated from T₀ to T₂. Epidemiological data were retrieved from the medical charts. Statistical analyses were performed for the entire cohort and subgroups regarding preoperative treatment and type of disease. Results: Seventy-seven patients were included in the study. T4 and thyroglobulin levels increased significantly from T₀ to T₁. TSH, T4, T3, and thyroglobulin levels decreased significantly from T₁ to T₂. Conclusions: Our study confirmed the hypothesis of variable kinetics of thyroid hormone levels associated with the manipulation of the thyroid gland during surgery, but none of these changes resulted in clinical effects, including thyrotoxicosis.

Thyroid storm without precipitating factors in a previous healthy child: A case report

The Thyroid Storm (TS) is the severest form of thyrotoxicosis and is associated with a high mortality rate. TS presents with fever, tachycardia, gastrointestinal symptoms, and central nervous system dysfunction and may be overlooked if patients do not present thyrotoxic symptoms or have precipitating factors. We reported a pediatric case of TS with mild proptosis but no obvious precipitating factors in a previously healthy child. A 9-year-old, female patient with a history of attention-deficit hyperactivity disorder presented with the complaint of frequent vomiting. She was alert but lethargic with fever and tachycardia. Physical examination was unremarkable except for coolness in the extremities and a delayed capillary refill time of two seconds. Fluid resuscitation was ineffective in alleviating the tachycardia. Additional history-taking revealed a one-month history of mild proptosis but no other thyrotoxic findings or precipitating factors were found. Markedly elevated thyroxine and triiodothyronine and suppressed thyroid-stimulating hormone on thyroid function tests led to a diagnosis of TS. Methimazole, potassium iodine, bisoprolol, and hydrocortisone were administered. Her vital signs and thyroid functions gradually improved, and she was discharged 18 days after admission without any serious complications. She is currently euthyroid and clinically stable on 5 mg of methimazole at three months after admission. When tachycardia that is resistant to usual resuscitation is found, careful history-taking and physical examination targeting thyroid disorders should be performed to assess for TS.

Severe Hyperthyroidism and Complete Hydatidiform Mole in Perimenopausal Woman: Case Report and Literature Review

Gestational trophoblastic disease (GTD) represents a heterogeneous group of disorders within placental trophoblastic cells that are rather rare in perimenopausal ages. One of its complications is the development of secondary clinical hyperthyroidism, which can be potentially complicated if not properly and early recognized. We report the case of a 50-year-old perimenopausal woman, gravida 2 para 2, who presented to the emergency department with severe acute lower abdominal pain and abnormal uterine bleeding for one month. She also reported abnormal sweating and palpitation for a one-week duration and amenorrhea for the previous three months. Abdominal examination showed a pelvic mass resembling a 15-week sized uterus. Serum β-hCG levels were strongly increased, and abdomen ultrasound displayed an enlarged uterus with “snow-storm” features, compatible with the diagnosis of GTD. Laboratory data revealed suppressed TSH levels and high free thyroxine and free triiodothyronine levels (4 and 1.5 times above the upper limit of normality, respectively). Thyrotropin-receptor antibodies (TRAb) levels were negative, and thyroid ultrasound excluded major structural disease. She was managed with anti-thyroid drugs, Lugol’s iodine, beta-blockers, and steroids during preoperative care. Thereafter, she underwent surgery, being diagnosed with a hydatidiform mole postoperatively. Her thyroid function returned to normal after three months, without the further need for antithyroid drugs. This case highlights the importance of considering GTD as an aetiology for thyrotoxicosis in perimenopausal women, especially in the absence of findings suggesting primary thyroid disease.

Thyrotoxicosis-Induced Cardiomyopathy Complicated by Refractory Cardiogenic Shock Rescued by Extracorporeal Membrane Oxygenation

Patient: Male 53-year-old

Final Diagnosis: Thyrotoxicosis-induced cardiomyopathy

Symptoms: Dyspnea

Medication:—

Clinical Procedure: —

Specialty: Cardiology • Critical Care Medicine

Successful Stabilization of Thyroid Storm Precipitated by Medication Noncompliance and Complicated Urinary Tract Infection: A Case Report

Thyroid storm is a rare but life-threatening condition that can occur in the setting of incompletely treated or untreated hyperthyroidism, and is often precipitated by recent infection, surgery, or trauma. We present a fascinating case report of the successful stabilization of a 29-year-old female, recently diagnosed with hyperthyroidism and non-compliant with medications, who presented with thyroid storm in the setting of sepsis secondary to right-sided pyelonephritis, non-ST-segment elevation myocardial infarction (NSTEMI) type 2, and hyperbilirubinemia. Management was further complicated by electrolyte imbalances secondary to severe diarrhea due to the thyroid storm and pancytopenia likely due to aggressive hydration. This case is demonstrative of the importance of early recognition, timely management, and patient education of life-threatening endocrine disorders such as severe thyrotoxicosis.

COVID-19 and thyroid function: What do we know so far?

Coronavirus disease 2019 (COVID-19) was characterized as a pandemic in March, 2020 by the World Health Organization. COVID-19 is a respiratory syndrome that can progress to acute respiratory distress syndrome, multiorgan dysfunction, and eventually death. Despite being considered a respiratory disease, it is known that other organs and systems can be affected in COVID-19, including the thyroid gland. Thyroid gland, as well as hypothalamus and pituitary, which regulate the functioning of most endocrine glands, express angiotensin-converting enzyme 2 (ACE2), the main protein that functions as a receptor to which SARS-CoV-2 binds to enter host cells. In addition, thyroid gland is extremely sensitive to changes in body homeostasis and metabolism. Immune system cells are targets for thyroid hormones and T3 and T4 modulate specific immune responses, including cell-mediated immunity, natural killer cell activity, the antiviral action of interferon (IFN) and proliferation of T- and B-lymphocytes. However, studies show that patients with controlled hypothyroidism and hyperthyroidism do not have a higher prevalence of COVID-19, nor do they have a worse prognosis when infected with the virus. On the other hand, retrospective observational studies, prospective studies, and case reports published in the last two years reported abnormal thyroid function related to acute SARS-CoV-2 infection or even several weeks after its resolution. Indeed, a variety of thyroid disorders have been documented in COVID-19 patients, including non-thyroidal illness syndrome (NTIS), subacute thyroiditis and thyrotoxicosis. In addition, thyroid disease has already been reported as a consequence of the administration of vaccines against SARS-CoV-2. Overall, the data revealed that abnormal thyroid function may occur during and in the convalescence post-COVID condition phase. Although the cellular and molecular mechanisms are not completely understood, the evidence suggests that the "cytokine storm" is an important mediator in this context. Thus, future studies are needed to better investigate the pathophysiology of thyroid dysfunction induced by COVID-19 at both molecular and clinical levels.

Case Report: Occurrence of Thyroid Storm in a Young Patient With Recurrent Diabetic Ketoacidosis

BACKGROUND

Thyroid storm (TS) is a fatal disease that leads to multiple organ failure and requires prompt diagnosis. Diabetic ketoacidosis (DKA) is a trigger for thyroid crisis. However, TS and DKA rarely occur simultaneously. Moreover, owing to the rarity of the co-occurrence, the clinical course remains unclear. In this study, we present a case of TS that developed during the follow-up for repeated DKA in a young patient.

CASE PRESENTATION

A 25-year-old man with a history of recurrent DKA was brought to the emergency room frequently with similar symptoms. DKA treatment was initiated, but his tachycardia and disturbance of consciousness did not improve. Further examination of the patient revealed a Burch-Wartofsky Point Scale score of 80 points, consistent with the Japan Thyroid Association criteria. Therefore, DKA coexisting with TS was diagnosed. Antithyroid medication, inorganic iodine, and corticosteroids were then started as treatment for TS, and β-blockers were administered to manage tachycardia. With these treatments, the patient's health improved and he recovered.

CONCLUSIONS

In severe cases of recurrent DKA, the presence of TS should be considered, and early treatment should be initiated before the patient's condition worsens.

OUP accepted manuscript

Thyroid storm (TS) is a rare but life-threatening complication of hyperthyroidism in which multiorgan failure (MOF) is the most common cause of death. Early diagnosis and treatment of TS are challenging. We presented two cases with refractory TS complicated with arrhythmia, cardiac arrest, cardiogenic shock and MOF and were not responding to medical treatment, therapeutic plasma exchange or continuous renal replacement therapy. The combination of extracorporeal membrane oxygenation (ECMO) and early thyroidectomy was the mainstay treatment that was performed with no complications. MOF was resolved and patients were doing well in the outpatient clinic follow-up. Precautions concerning the beta blockers and anti-thyroid medications use in TS, especially in the acute setting, should be considered. Upon its availability, the use of ECMO and early thyroidectomy is efficient. This is most applicable in patients not responding to medical treatment or patients who develop complications related to the TS and its medical treatment.

Delphi Consensus on American Society of Anesthesiologists' Physical Status Classification in an Asian Tertiary Women's Hospital

Background

The American Society of Anesthesiologists (ASA) score is generated based on patients’ clinical status. Accurate ASA classification is essential for the communication of perioperative risks and resource planning. Literature suggests that ASA classification can be automated for consistency and time-efficiency. To develop a rule-based algorithm for automated ASA classification, this study seeks to establish consensus in ASA classification for clinical conditions encountered at a tertiary women’s hospital.

Methods

Thirty-seven anesthesia providers rated their agreement on a 4-point Likert scale to ASA scores assigned to items via the Delphi technique. After Round 1, the group’s collective responses and individual item scores were shared with participants to improve their responses for Round 2. For each item, the percentage agreement (‘agree’ and ‘strongly agree’ responses combined), median (interquartile range/IQR), and SD were calculated. Consensus for each item was defined as a percentage agreement ≥ 70%, IQR ≤ 1.0, and SD < 1.0.

Results

All participants completed the study and none had missing data. The number of items that reached consensus increased from 25 (51.0%) to 37 (75.5%) in the second Delphi round, particularly for items assigned ASA scores of III and IV. Nine items, which pertained to alcohol intake, asthma, thyroid disease, limited exercise tolerance, and stable angina, did not reach consensus even after two Delphi rounds.

Conclusions

Delphi consensus was attained for 37 of the 49 study items (75.5%), facilitating their incorporation into a rule-based clinical support system designed to automate the prediction of ASA classification.

Diltiazem-Induced Reversible Cardiogenic Shock in Thyroid Storm

Early recognition of underlying thyroid disease in patients presenting with new-onset tachyarrhythmia is central to management, as usual rate-control strategies can result in significant mortality and morbidity. Hyperthyroidism-induced cardiomyopathy complicated by cardiogenic shock is a life-threatening condition. Thyroid storm can lead to irreversible cardiovascular collapse and death if proper treatment is not initiated as soon as possible. In this case, we report a 44-year-old female who presented to the emergency department (ED) with the chief complaints of anxiety and palpitations. Her past medical history was significant for anxiety, but she was otherwise healthy. An electrocardiogram (ECG) in the ED demonstrated atrial fibrillation (A. fib) with rapid ventricular response (RVR) felt to be secondary to thyroid storm based on the Burch-Wartofsky point scale (BWPS), which is a quantitative diagnostic tool that uses clinical manifestation in diagnosing thyroid storm. The patient was initially managed with a continuous infusion of diltiazem to achieve rate control with a goal heart rate <115 beats per minute (bpm). Shortly after initiating the infusion, the patient developed signs and symptoms consistent with cardiogenic shock. Bedside echocardiogram revealed an estimated ejection fraction (EF) <10% with concomitant pulmonary edema. Repeat echocardiogram within 72 hours after stopping diltiazem and starting appropriate treatment for thyroid storm showed improvement of EF to 35%. 

Graves' disease treated by complementary medicine leading to thyroid storm: A case report

Background:

Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis and can be precipitated by several factors. We described a thyroid storm precipitated by a long-term treatment using homeopathic medicine containing iodine.

Case presentation:

A 55-year-old Italian woman was admitted to our Sub-Intensive Care Unit with the diagnosis of congestive heart failure and thyrotoxicosis. She has been diagnosed with Graves’ disease two years before; she refused conventional therapy and in the preceding six months had been using phytotherapeutic and homeopathic medicine. We found serum and urine iodine levels consistent with severe intoxication by iodine (serum iodine: 42100 mcg/L and urinary iodine: 4223 mcg/L, respectively). After a few hours, the patient went into cardiac arrest. She was subjected to invasive ventilation, dialyzed with continuous veno-venous hemofiltration and treated with vasoactive amines.

Conclusion:

The high level of iodemia manifested in our patient - around a thousand times greater than the normal range and itself associated with fatal outcomes - was caused by long-term homeopathic treatment. This long-term treatment has two consequences: first, iodine load-precipitated hyperthyroidism in thyroid storm, and secondly, it prevents us from treating patients with inorganic iodide.

Increased Ileostomy Output as an Indicator of Thyroid Storm in a Patient without an Established History of Underlying Thyroid Disease

Patient: Male, 27-year-old

Final Diagnosis: Thyroid storm

Symptoms: Abdominal pain • agitation • fever • high ileostomy output • tachycardia • tachypnea • weight loss

Medication: —

Clinical Procedure: —

Specialty: Critical Care Medicine

Metastatic choriocarcinoma in a young woman presenting as thyroid storm: a case report

Background

Thyroid storm is an endocrine emergency and life-threatening condition discovered in 1926. There is no specific laboratory parameter that can differentiate or distinguish between thyroid storm and primary hyperthyroidism. Diagnosis is made on a clinical scoring system, including the Burch–Wartofsky point scale and Japanese Thyroid Association scoring system. The management is early diagnosis, immediate initiation of anti-thyroid medications, intensive care monitoring, and prevention of multiorgan failure.

Case presentation

A 30-year-old Pakistani female presented with complaint of headache, vomiting, and generalized weakness for 3 weeks. She had an episode of seizure-like activity at home, and so was rushed to the emergency department. A detailed thyroid examination revealed a soft, nontender gland with no enlargement or bruit and no exophthalmos. Her thyroid-stimulating hormone was extremely low, with high free triiodothyronine and thyroxine. Thyroglobulin was 425 ng/ml (normal reference range ≤ 55 ng/ml), and thyroid-stimulating hormone receptor antibody was 0.87 IU/L (normal reference range 0–1.75 IU/L). She had high levels of beta-human chorionic gonadotropin hormone on initial presentation. Transvaginal ultrasound showed no intrauterine pregnancy, but an echogenic focus was found adherent to the right ovary with no vascularity. With the chief complaint of headache, she underwent magnetic resonance imaging of the brain that showed multiple scattered hemorrhagic lesions in supratentorial and infratentorial brain parenchyma that were highly suspicious for metastases. Computed tomography scan of the chest, abdomen, and pelvis revealed multiple neoplastic lesions in the lung, liver, spleen, and kidneys. A Tru-Cut liver biopsy showed linear cores of liver tissue with metastatic carcinoma with morphological features consistent with choriocarcinoma. Our patient scored 65 on the Burch–Wartofsky point scale. As per the Japanese Thyroid Association scoring system, our patient met the criteria for a “definite thyroid storm.” She had initiated propranolol to achieve adequate control of her heart rate and dexamethasone. Carbimazole was started to control her thyroid function. Her thyroid function after 2 weeks of treatment showed significant improvement. Methotrexate and etoposide were given for choriocarcinoma. She made a good recovery and was discharged home. She will undergo rehabilitation along with ongoing chemotherapy (methotrexate and etoposide weekly till beta-human chorionic gonadotropin levels normalize). Unless her source of beta-human chorionic gonadotropin is carefully under control, she will continue to take anti-thyroid medications.

Conclusion

Choriocarcinoma is not only associated with hyperthyroidism but can induce thyroid storm. Beta-human chorionic gonadotropin is directly associated with promoting thyroid dysfunction. Patients with gestational trophoblastic disease should be under close surveillance to prevent thyroid storms.