Early administration of glucocorticoid for thyroid storm: analysis of a national administrative database

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.

Thyroid Storm Superimposed on Gestational Hypertension: A Case Report and Review of Literature

A thyroid storm is an extreme manifestation of thyrotoxicosis, and is life threatening without an early diagnosis. Pregnancy or childbirth may worsen maternal hyperthyroidism or induce the development of a thyroid storm. Gestational hypertension, a disorder defined as new-onset hypertension, develops after 20 weeks of gestation and shares symptoms with a thyroid storm. The diagnosis of a thyroid storm may be challenging in patients with gestational hypertension. To highlight the significance of early thyrotoxicosis-related gastrointestinal symptoms, we report a case of a 38-year-old woman with a twin pregnancy, who was diagnosed with gestational hypertension, and then developed a thyroid storm during the peripartum period. She complained of nausea and abdominal pain, followed by tachycardia, hypertension, and a disturbance of consciousness with desaturation. After emergency caesarean section, fever, diarrhea, and high-output heart failure, with pulmonary edema, were noted during the postoperative period in the intensive care unit. The diagnosis of a thyroid storm was confirmed using the Burch–Wartofsky point scale, which was 75 points. In this patient, the uncommon gastrointestinal symptoms, as initial manifestations of thyrotoxicosis, indicated the development of a thyroid storm. The distinguished presentation of thyrotoxicosis-induced cardiomyopathy and peripartum cardiomyopathy also helped in the differential diagnosis between a thyroid storm and gestational hypertension. Aggressive treatment for thyrotoxicosis should not be delayed because of a missed diagnosis.

Effects of ondansetron use on outcomes of acute kidney injury in critically ill patients: An analysis based on the MIMIC-IV database

PURPOSE

Acute kidney injury (AKI) in intensive care units (ICUs) is a health priority with limited treatment options. This study aimed to estimate the effects of ondansetron use on AKI patient outcomes.

MATERIALS AND METHODS

We used the MIMIC-IV database to compare AKI patient mortality in the ICU with and without ondansetron and calculated hazard ratios (HRs) with 95% confidence intervals (95%CI) by multivariable Cox regression. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were applied to adjust for confounding factors.

RESULTS

In total, 26,004 AKI patients were included. Ondansetron use reduced in-hospital mortality risk by 16% among AKI patients (HR: 0.84, 95%CI: 0.77-0.90, p < 0.001). In-hospital mortality was significantly reduced among patients administered ondansetron at AKI stage 1 (11.4% vs. 16.5%. p < 0.001) and stage 2 (16.1% vs. 19.6%. p < 0.001) but not stage 3 (24.0% vs. 23.9%. p = 0.890). Patients younger than 60 years or receiving surgery received greater benefits from ondansetron use. (HR: 0.62, 95%CI:0.53-0.72 and HR: 0.59, 95%CI:0.50-0.69, respectively).

CONCLUSIONS

This cohort study showed that ondansetron use is significantly associated with reduced risk-adjusted in-hospital mortality in stages 1 and 2 AKI patients in the ICU. Further randomized controlled trials are needed.

Beyond classic concepts in thyroid homeostasis: Immune system and microbiota

It has long been known that thyroid hormones have implications for multiple physiological processes and can lead to serious illness when there is an imbalance in its metabolism. The connections between thyroid hormone metabolism and the immune system have been extensively described, as they can participate in inflammation, autoimmunity, or cancer progression. In addition, changes in the normal intestinal microbiota involve the activation of the immune system while triggering different pathophysiological disorders. Recent studies have linked the microbiota and certain bacterial fragments or metabolites to the regulation of thyroid hormones and the general response in the endocrine system. Even if the biology and function of the thyroid gland has attracted more attention due to its pathophysiological importance, there are essential mechanisms and issues related to it that are related to the interplay between the intestinal microbiota and the immune system and must be further investigated. Here we summarize additional information to uncover these relationships, the knowledge of which would help establish new personalized medical strategies.

Focus on Autoimmune Myocarditis in Graves' Disease: A Case-Based Review

The manifestations of hyperthyroidism-related myocardial damage are multitudinous, including arrhythmia, dilated cardiomyopathy, valvular diseases, and even cardiogenic shock. Acute myocarditis induced by thyrotoxicosis had been reported in a few studies. However, attention on its prevalence and underlying mechanisms is sorely lacking. Its long-term harm is often ignored, and it may eventually develop into dilated cardiomyopathy and heart failure. We report a case of Graves' disease with a progressive elevation of hypersensitive cardiac troponin-I at several days after discontinuation of the patient's anti-thyroid drugs. Cardiac magnetic resonance imaging (CMRI) showed inflammatory edema of some cardiomyocytes (stranded enhanced signals under T2 mapping), myocardial necrosis (scattered enhanced signals under T1 late gadolinium enhancement) in the medial and inferior epicardial wall, with a decreased left ventricular systolic function (48%), which implied a possibility of acute myocarditis induced by thyrotoxicosis. The patient was then given a transient glucocorticoid (GC) treatment and achieved a good curative effect. Inspired by this case, we aim to systematically elaborate the pathogenesis, diagnosis, and treatment of hyperthyroidism-induced autoimmune myocarditis. Additionally, we emphasize the importance of CMRI and GC therapy in the diagnosis and treatment of hyperthyroidism-related myocarditis.

Bacillus subtilis-Based Probiotic Improves Skeletal Health and Immunity in Broiler Chickens Exposed to Heat Stress

Simple Summary

High ambient temperature is a major environmental stressor affecting the physiological and behavioral status of animals, increasing stress susceptibility and immunosuppression, and consequently increasing intestinal permeability (leaky gut) and related neuroinflammation. Probiotics, as well as prebiotics and synbiotics, have been used to prevent or decrease stress-associated detrimental effects on physiological and behavioral homeostasis in humans and various animals. The current data indicate that a dietary probiotic supplement, Bacillus subtilis, reduces heat stress-induced abnormal behaviors and negative effects on skeletal health in broilers through a variety of cellular responses, regulating the functioning of the microbiota–gut–brain axis and/or microbiota-modulated immunity during bone remodeling under thermoneutral and heat-stressed conditions.

Abstract

The elevation of ambient temperature beyond the thermoneutral zone leads to heat stress, which is a growing health and welfare issue for homeothermic animals aiming to maintain relatively constant reproducibility and survivability. Particularly, global warming over the past decades has resulted in more hot days with more intense, frequent, and long-lasting heat waves, resulting in a global surge in animals suffering from heat stress. Heat stress causes pathophysiological changes in animals, increasing stress sensitivity and immunosuppression, consequently leading to increased intestinal permeability (leaky gut) and related neuroinflammation. Probiotics, as well as prebiotics and synbiotics, have been used to prevent or reduce stress-induced negative effects on physiological and behavioral homeostasis in humans and various animals. The current data indicate dietary supplementation with a Bacillus subtilis-based probiotic has similar functions in poultry. This review highlights the recent findings on the effects of the probiotic Bacillus subtilis on skeletal health of broiler chickens exposed to heat stress. It provides insights to aid in the development of practical strategies for improving health and performance in poultry.