2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

Clinical Efficacy of Beta-1 Selective Beta-Blockers Versus Propranolol in Patients With Thyroid Storm: A Retrospective Cohort Study

OBJECTIVES

Thyroid storm is the most severe manifestation of thyrotoxicosis. Beta-blockers are among the standard treatment regimens for this condition, with propranolol being the historically preferred option. However, 2016 guidelines issued by the Japan Thyroid Association and the Japan Endocrine Society recommend the use of beta-1 selective beta-blockers over nonselective beta-blockers, such as propranolol. Nevertheless, evidence supporting this recommendation is limited. Herein, we aimed to investigate the in-hospital mortality of patients with thyroid storms based on the choice of beta-blockers.

DESIGN

Retrospective cohort study.

SETTING

The Diagnosis Procedure Combination database, a national inpatient database in Japan.

PATIENTS

Patients hospitalized with thyroid storm between April 2010 and March 2022.

INTERVENTIONS

Propensity-score overlap weighting was performed to compare in-hospital mortality between patients who received beta-1 selective beta-blockers and those who received propranolol. Subgroup analysis was also conducted, considering the presence or absence of acute heart failure.

MEASUREMENTS AND MAIN RESULTS

Among the 2462 eligible patients, 1452 received beta-1 selective beta-blockers and 1010 received propranolol. The crude in-hospital mortality rates were 9.3% for the beta-1 selective beta-blocker group and 6.2% for the propranolol group. After adjusting for baseline variables, the use of beta-1 selective beta-blockers was not associated with lower in-hospital mortality (6.3% vs. 7.4%; odds ratio, 0.85; 95% CI, 0.57-1.26). Furthermore, no significant difference in in-hospital mortality was observed in patients with acute heart failure.

CONCLUSIONS

In patients with thyroid storm, the choice between beta-1 selective beta-blockers and propranolol did not affect in-hospital mortality, regardless of the presence of acute heart failure. Therefore, both beta-1 selective beta-blockers and propranolol can be regarded as viable treatment options for beta-blocker therapy in cases of thyroid storm, contingent upon the clinical context.

Case report: management of a young male patient with diabetic ketoacidosis and thyroid storm

This report describes a case of concomitant diabetic ketoacidosis (DKA) and thyroid storm (TS) in a 20-year-old male patient that presented both diagnostic and management challenges owing to their intricate interrelationship in endocrine-metabolic disorders. The patient, previously diagnosed with type 1 diabetes mellitus (T1DM) and hyperthyroidism, was admitted to the emergency department with symptoms of DKA and progressive exacerbation of TS. Initial treatment focused on correcting DKA; as the disease progressed to TS, it was promptly recognized and treated. This case emphasizes the rarity of simultaneous occurrence of DKA and TS, as well as the challenges in clinical diagnosis posed by the interacting pathophysiological processes and overlapping clinical manifestations of DKA and TS. The patient's treatment process involved multiple disciplines, and after treatment, the patient's critical condition of both endocrine metabolic diseases was alleviated, after which he recovered and was eventually discharged from the hospital. This case report aims to emphasize the need for heightened awareness in patients with complex clinical presentations, stress the possibility of concurrent complications, and underscore the importance of prompt and collaborative treatment strategies.

Thyroid storm after coronavirus disease 2019 mRNA vaccination in a patient with a history of Graves' disease after coronavirus disease 2019 infection

We report a case where the patient may have developed Graves' disease after COVID-19 infection, and where the COVID-19 vaccination may have exacerbated the condition, inducing the onset of a thyroid storm. Although any association between the vaccine and the onset of thyroid disease is impossible to demonstrate through a single case, the antecedent COVID-19 infection and COVID-19 messenger ribonucleic acid vaccination may have synergistically contributed to the development of Graves' disease followed by thyroid storm.

Thyroid storm-induced acute liver dysfunction and portal hypertension in a patient with Graves' disease: a case report

Thyroid storm is a life-threatening condition associated with multiorgan dysfunction and decompensation. We report the case of a 41-year-old woman having Graves' disease presented with thyroid storm complicated with liver dysfunction and portal hypertension in the absence of congestive heart failure or known liver disease. After successful therapeutic management, all biological, clinical and morphological abnormalities regressed.

Case report and literature review: A thyroid storm patient with severe acute hepatic failure treated by therapeutic plasma exchange and a double plasma molecular absorption system

Thyroid storm (TS) leading to acute liver failure is rare but fatal in clinical practice and hepatic failure can remarkably limit medication options for TS. We successfully cured a patient with TS complicated with acute hepatic failure using therapeutic plasma exchange (TPE) and a double plasma molecular absorption system (DPMAS) and summarized the case characteristics of 10 similar critical patients reported worldwide. We recommend that patients with TS complicated with liver failure disuse propylthiouracil or methimazole. TPE should be utilized to rapidly decrease thyroid hormone levels, and DPMAS should be considered for supportive treatment in the presence of hepatic encephalopathy or dramatic bilirubin elevations.

Fighting thyrotoxicosis with therapeutic plasma exchange: A case report

Thyrotoxicosis is the clinical condition resulting from an excess of thyroid hormones for any reason. The main causes are Graves-Basedow disease, toxic multinodular goitre and toxic adenoma. The medical treatment to control thyroid function includes antithyroid drugs, beta blockers, iodine solutions, corticosteroids and cholestyramine. Although therapeutic plasma exchange is not generally part of the therapy, it is an alternative as a preliminary stage before the definitive treatment. This procedure makes it possible to eliminate T4, T3, TSI, cytokines and amiodarone. In most cases, more than one cycle is necessary, either daily or every three days, until clinical improvement is observed. The effect on thyrotoxicosis is temporary, with an approximate duration of 24-48h. This approach has been proposed as a safe and effective alternative when the medical treatment is contraindicated or not effective, and when there is multiple organ failure or emergency surgery is required.

Thyroid storm in pregnancy: a review

BACKGROUND

Thyroid storm is a state of circulating thyroid hormone excess leading to multiorgan dysfunction and systemic decompensation. It typically occurs in the setting of poorly controlled hyperthyroidism and a precipitating illness or event. Management of thyroid storm in pregnancy poses unique diagnostic and therapeutic challenges.

MAIN BODY

Thyroid storm is a clinical diagnosis characterized by hyperpyrexia, tachyarrhythmias, congestive heart failure, gastrointestinal and neuropsychiatric disturbances. However, diagnostic scoring systems have not been validated in pregnancy. Treatment involves specialist consultation, supportive care, and pharmacological options such as anti-thyroid medications, beta blockers, iodine solutions, glucocorticoids, and cholestyramine. These must be adapted and modified in pregnancy to prevent fetal and maternal complications.

CONCLUSION

There is a critical need to recognize thyroid storm during pregnancy and initiate proper medical interventions promptly.

Atrioventricular block in patients with hyperthyroidism: a narrative review

Atrioventricular block (AVB) is a rare cardiac manifestation of hyperthyroidism (HTH). The scientific literature contains multiple reports of AVB in patients with HTH, ranging from subclinical to overt HTH and even thyroid storm. However, much remains unknown about the true prevalence, clinical course, optimal management, and outcomes of AVB in patients with HTH. Such patients are possibly overtreated with pacemakers because of a lack of understanding that AVB might be secondary to the hyperthyroid state and thus reversible. This narrative review discusses the pathophysiology of AVB in patients with HTH in the context of the available evidence.

A Case of Acute Neurologic Deficit and Hypoglycemia in the Setting of Thyroid Storm and Diabetic Ketoacidosis: A New Clinical Scenario

The simultaneous development of diabetic ketoacidosis (DKA) and thyroid storm (TS) is a rare but potentially lifethreatening condition that requires immediate and targeted treatment. However, their combined diagnosis poses a serious challenge because of the similarities between their clinical manifestations. To date, only a few dozen cases have been described; most of which have been linked to the progression of thyrotoxicosis or uncontrolled hyperglycemia as contributing factors. We present the case of a 37-year-old woman with type 1 diabetes mellitus and Graves' disease who presented with both TS and DKA. She was initially admitted to the emergency department as a suspected case of stroke. Severe hypoglycemia significantly lowered her alertness to TS and probably provoked a sharp hyperthyroid decompensation, thereby leading to subsequent DKA development.

Advancing Preoperative Strategies for Thyroidectomy in Graves' Disease: A Narrative Review

Graves' disease is an autoimmune disorder characterized by thyroid-stimulating antibodies that can potentially lead to thyrotoxicosis, goiter, skin disease, and eye disease. Available treatment options for Graves' disease include management with antithyroid drugs (ATDs), thyroid ablation with radioactive iodine (RAI), and surgical thyroid gland removal. For individuals unable to reach a normal thyroid hormone level, promptly considering a thyroidectomy is essential. Preoperative strategies to achieve a euthyroid state prevent thyroid storms and minimize postoperative complications and are therefore crucial. While variations in professional guidance exist, this review focuses on standard medical interventions as well as compares respective guidelines set forth by the American Thyroid Association, the European Thyroid Association, the American Association of Clinical Endocrinology, and the American Association of Endocrine Surgeons. There is consensus among these organizations underscoring the importance of rendering patients euthyroid prior to surgery and the use of ATDs. Most guidelines recommend screening for vitamin D deficiency as well as endorse thyroidectomy as the preferred treatment option for hyperthyroidism with skilled surgeons. Nevertheless, discrepancies do become apparent in aspects such as potassium iodide (SSKI) course duration and preoperative dexamethasone administration. By understanding these differing approaches, healthcare professionals can more effectively manage Graves' disease prior to surgery, resulting in improved patient outcomes and enhanced surgical success.

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.

Hyperthyroidism: A Review

Importance

Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality.

Observations

The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L.

Conclusions and Relevance

Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.

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.

Comparing the Incidence of Propranolol and Esmolol-Related Cardiac Arrest in Patients With Thyroid Storm: A Systematic Literature Review

A precarious complication of thyrotoxicosis, or thyroid storm, is the increased risk of cardiomyopathy, which leads to circulatory collapse and cardiopulmonary arrest. It is crucial to promptly identify this condition to prevent significant deterioration of the left ventricular function and cardiogenic shock. This article seeks to examine published research that emphasizes the connection between thyroid storm and beta-blocker usage in relation to cardiogenic collapse and provides management recommendations. The search was performed on September 9, 2022, using PubMed, Science Direct, and Google Scholar libraries. A systematic exploration was carried out using the keywords Thyroid Storm AND cardiogenic Shock AND cardiac arrest AND beta blocker. The use of beta blockers as part of thyroid storm management was linked to the development of cardiogenic collapse and cardiac arrest. Ultra-short-acting beta-blockers like esmolol were a safer option than propranolol in treating patients with a thyrotoxic storm.

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.

The EANM guideline on radioiodine therapy of benign thyroid disease

This document provides the new EANM guideline on radioiodine therapy of benign thyroid disease. Its aim is to guide nuclear medicine physicians, endocrinologists, and practitioners in the selection of patients for radioiodine therapy. Its recommendations on patients' preparation, empiric and dosimetric therapeutic approaches, applied radioiodine activity, radiation protection requirements, and patients follow-up after administration of radioiodine therapy are extensively discussed.

Case report: Impact of hyperthyroidism on psychotic symptoms in schizophrenia comorbid with Graves' disease

Introduction

Auditory hallucinations are the most common type of hallucinations observed in schizophrenia; however, visual hallucinations are not uncommon. In Graves' disease, depression, hypomania, and psychosis can occur. While the association between Graves' disease and psychosis has been explored, understanding of the specific impact of thyroid dysfunction severity on psychiatric symptom severity is limited. Here, we present a case report of a patient with schizophrenia comorbid with Graves' disease whose psychotic symptoms were impacted by hyperthyroidism.

Case

The patient was a 32-year-old Japanese woman who presented with auditory and visual hallucinations, agitation, and pressured speech. The patient was diagnosed with schizophrenia comorbid with Graves' disease and thyroid storm. The patient's psychotic symptoms were found to be associated with fluctuations in thyroid hormone levels, and visual hallucinations were observed only during thyroid storms. Treatment involved dexamethasone, potassium iodide, bisoprolol fumarate, and methimazole for thyrotoxicosis, and a blonanserin transdermal patch, paliperidone, and paliperidone palmitate for psychotic symptoms. The patient's auditory and visual hallucinations improved with antipsychotic treatment and decreased thyroid hormone levels.

Conclusion

This case highlights the importance of monitoring thyroid function in patients with schizophrenia, particularly those with comorbid Graves' disease. The correlation between psychiatric symptoms and thyroid hormone levels was demonstrated on an individual level over time, with symptoms worsening as thyroid hormone levels increased. Additionally, our case suggests that abnormally high thyroid hormone levels may trigger visual hallucinations in individuals with schizophrenia. Further studies are needed to elucidate the underlying mechanisms and potential treatment implications of this association.

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.

Case report: Thyroid storm in a three-year-old girl presenting with febrile status epilepticus and hypoglycemia

Thyroid storm, though extremely rare in toddlers, requires prompt diagnosis and treatment because it can be fatal if left untreated. However, thyroid storm is not often considered in the differential diagnosis of a febrile convulsion due to its rarity in children. Herein, we report the case of a 3-year-old girl with thyroid storm who presented with febrile status epilepticus. Although the seizure was stopped by diazepam administration, her tachycardia and widened pulse pressure persisted, and severe hypoglycemia was observed. Based on the findings of thyromegaly, a history of excessive sweating and hyperactivity, and a family history of Graves' disease, she was eventually diagnosed with a thyroid storm. The patient was successfully treated with thiamazole, landiolol, hydrocortisone, and potassium iodide. Propranolol, a non-selective β-blocker, has been used to manage tachycardia during thyroid storm. However, a cardio-selective β1-blockers, landiolol hydrochloride, was used in our case to avoid worsening hypoglycemia. Febrile status epilepticus is one of the most common medical emergencies in childhood; it is necessary to rule out treatable underlying critical diseases such as septic meningitis and encephalitis. Thyroid storm should be considered in children presenting with prolonged febrile convulsion accompanied by findings that are not usually observed with febrile convulsions.

Anaesthetic management of thyroid storm in a patient with Friederich's ataxia. A case report

A 26-year-old patient with Friederich's ataxia with hypertrophic obstructive cardiomyopathy undergoing total thyroidectomy due to persistent amiodarone-induced thyrotoxicosis (despite high doses of antithyroid drugs and corticosteroids), presented an intraoperative episode suggestive of thyroid storm. Thyroid storm is an endocrine emergency that is associated with high morbidity and mortality. Early diagnosis and treatment, which is of vital importance to improve survival, includes symptomatic treatment, treatment of cardiovascular, neurological, and/or hepatic manifestations and thyrotoxicosis, measures to suppress or avoid triggering stimuli, and definitive treatment.

Thyrotoxicosis and Impending Thyroid Storm: A Rare Paraneoplastic Syndrome in an Infant With Hepatoblastoma

Graves' disease is the most common cause of pediatric hyperthyroidism and thyrotoxicosis. Thyroid storm is a rare initial manifestation of Graves' disease and represents an endocrine emergency. We report a case of transient hyperthyroidism, possibly a paraneoplastic syndrome presenting as impending thyroid storm in a patient with undiagnosed hepatoblastoma. To our knowledge, this is the first case of this association reported in children. A previously healthy 21-month-old male presented with abdominal pain and unremitting tachycardia. He was managed for thyrotoxicosis and impending thyroid storm. He subsequently was found to have hepatomegaly leading to a diagnosis of hepatoblastoma. Autoimmune markers for Graves' disease were negative, along with a negative human chorionic gonadotropin. After initiation of neoadjuvant chemotherapy, he had complete resolution of thyrotoxicosis. Paraneoplastic syndromes may occur with any tumor. We present a unique case of a patient developing human chorionic gonadotropin-negative hyperthyroidism, possibly as a paraneoplastic syndrome from hepatoblastoma.

Coexistence of Graves' disease with acute rheumatic fever treated as thyroid storm in young Thai patient

OBJECTIVES

This report presents a case of acute onset of chorea, concurrent Graves' disease, and acute rheumatic fever in an 8-year-old female patient.

CASE PRESENTATION

The child had intermittent involuntary movement of all extremities and both eyes for 4 days, with a previous history of increased appetite, weight lost, and heat intolerance over a period of two months. Physical examination revealed fever, tachycardia, exophthalmos, eyelid retraction, as well as diffused thyroid enlargement. Initial clinical features and thyroid function testing suggested a thyroid storm due to Graves' disease. Methimazole, propranolol, potassium iodide (SSKI), and dexamethasone were prescribed. Congestive heart failure developed after propranolol and cardiovascular re-evaluation and Revised Jones criteria suggested acute rheumatic fever. Chorea was successfully treated with pulse methylprednisolone.

CONCLUSIONS

We reported Graves' disease patients with acute rheumatic fever simulating a thyroid storm. The underlying cardiac disease must be considered, especially where chorea and congestive heart failure are present.

Comparison of Propylthiouracil vs Methimazole for Thyroid Storm in Critically Ill Patients

Importance

Thyroid storm is the most severe form of thyrotoxicosis, with high mortality, and is treated with propylthiouracil and methimazole. Some guidelines recommend propylthiouracil over methimazole, although the difference in outcomes associated with each treatment is unclear.

Objective

To compare outcomes associated with use of propylthiouracil vs methimazole for the treatment of thyroid storm.

Design, Setting, and Participants

This comparative effectiveness study comprised a large, multicenter, US-based cohort from the Premier Healthcare Database between January 1, 2016, and December 31, 2020. It included 1383 adult patients admitted to intensive or intermediate care units with a diagnosis of thyroid storm per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes and treated with either propylthiouracil or methimazole. Analyses were conducted from July 2022 to February 2023.

Exposure

Patients received either propylthiouracil or methimazole for treatment of thyroid storm. Exposure was assigned based on the initial thionamide administered.

Main Outcomes and Measures

The primary outcome was the adjusted risk difference of in-hospital death or discharge to hospice between patients treated with propylthiouracil and those treated with methimazole, assessed by targeted maximum likelihood estimation.

Results

A total of 1383 patients (656 [47.4%] treated with propylthiouracil; mean [SD] age, 45 [16] years; 473 women [72.1%]; and 727 [52.6%] treated with methimazole; mean [SD] age, 45 [16] years; 520 women [71.5%]) were included in the study. The standardized mean difference for age was 0.056, and the standardized mean difference for sex was 0.013. The primary composite outcome occurred in 7.4% of of patients (102 of 1383; 95% CI, 6.0%-8.8%). A total of 8.5% (56 of 656; 95% CI, 6.4%-10.7%) of patients who initiated propylthiouracil and 6.3% (46 of 727; 95% CI, 4.6%-8.1%) who initiated methimazole died in the hospital (adjusted risk difference, 0.6% [95% CI, -1.8% to 3.0%]; P = .64). There were no significant differences in duration of organ support, total hospitalization costs, or rates of adverse events between the 2 treatment groups.

Conclusion and Relevance

In this comparative effectiveness study of a multicenter cohort of adult patients with thyroid storm, no significant differences were found in mortality or adverse events in patients who were treated with propylthiouracil or methimazole. Thus, current guidelines recommending propylthiouracil over methimazole for treatment of thyroid storm may merit reevaluation.

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.

Therapeutic Plasma Exchange for the Treatment of Hyperthyroidism: Approach to the Patient with Thyrotoxicosis or Antithyroid-Drugs Induced Agranulocytosis

Primary hyperthyroidism is an endocrine disorder characterized by excessive thyroid hormone synthesis and secretion by the thyroid gland. Clinical manifestations of hyperthyroidism can vary from subclinical to overt forms. In rare cases, hyperthyroidism may represent a clinical emergency, requiring admission to an intensive care unit due to an acute and severe exacerbation of thyrotoxicosis, known as a thyroid storm. First-line treatment of hyperthyroidism is almost always based on medical therapy (with thioamides, beta-adrenergic blocking agents, glucocorticoids), radioactive iodine or total thyroidectomy, tailored to the patient’s diagnosis. In cases of failure/intolerance/adverse events or contraindication to these therapies, as well as in life-threatening situations, including a thyroid storm, it is necessary to consider an alternative treatment with extracorporeal systems, such as therapeutic plasma exchange (TPE). This approach can promptly resolve severe conditions by removing circulating thyroid hormones. Here we described two different applications of TPE in clinical practice: the first case is an example of thyrotoxicosis due to amiodarone treatment, while the second one is an example of a severe adverse event to antithyroid drugs (agranulocytosis induced by methimazole).

Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report

BACKGROUND

Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital.

CASE PRESENTATION

The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient's symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient's condition.

CONCLUSION

If a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient's condition is critical, and early diagnosis will lead to a favorable outcome for the patient.

Thyroid storm and hypercalcemic crisis as a result of unconventional treatment of Graves’ disease

We present a case of severe thyroid storm with simultaneous hypercalcemic crisis resulting from excessive intake of 5% Lugol’s iodine solution (5% iodine, 15% potassium iodide, 85% water; 10 drops/day) and vitamin D3 (10000 IU/day) during 2 months of unconventional treatment in a 78-year-old female with a history of hyperthyroidism in course of Graves’ disease. Supplements were prescribed by herbalist/healer before admission to the hospital. At the clinic, we started  therapy with antithyroid drugs, inorganic iodide and corticosteroids but without positive effect. Patient’s condition kept deteriorating with loss of consciousness. Plasmapheresis (4 procedures) was required to successfully reduce thyroid hormone levels and finally total thyroidectomy was performed resulting in postoperative hypothyroidism and transient hypoparathyroidism. Additionally, patient suffered from serious complications such as Takotsubo cardiomyopathy and sepsis requiring intensive care unit. Treatment with corticosteroids led to secondary adrenal insufficiency. Following 2-month hospitalization, patient was discharged in stable condition.

Non-thionamide antithyroid drug options in Graves' hyperthyroidism

INTRODUCTION

The thionamide anti-thyroid drugs namely carbimazole, methimazole, and propylthiouracil, have been the predominant therapy modality for Graves' hyperthyroidism for over 60 years. Although these agents have proven efficacy and favorable side-effect profiles, non-thionamide alternatives are occasionally indicated in patients who are intolerant or unresponsive to thionamides alone. This review examines the available non-thionamide drug options for the control of Graves' hyperthyroidism and summarizes their clinical utility, efficacy, and limitations.

AREAS COVERED

We reviewed existing literature on mechanisms, therapeutic utility, and side-effect profiles of non-thionamide anti-thyroid drugs. Established non-thionamide agents act on various phases of the synthesis, release, and metabolism of thyroid hormones and comprise historical agents such as iodine compounds and potassium perchlorate as well as drug repurposing candidates like lithium, glucocorticoids, beta-blockers, and cholestyramine. Novel experimental agents in development target key players in Graves' disease pathogenesis including B-cell depletors (Rituximab), CD40 blockers (Iscalimab), TSH-receptor antagonists, blocking antibodies, and immune-modifying peptides.

EXPERT OPINION

Non-thionamide anti-thyroid drugs are useful alternatives in Graves' hyperthyroidism and more clinical trials are needed to establish their safety and long-term efficacy in hyperthyroidism control. Ultimately, the promise for a cure will lie in novel approaches that target the well-established immunopathogenesis of Graves' disease.

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.

[Two cases of ischemic stroke due to low protein C caused by severe hyperthyroidism]

We reported two patients with acute ischemic stroke who had presented with symptoms of thyroid storm. Case1: A 43-year-old man abruptly developed left hemiparesis caused by the right middle cerebral artery occlusion. Cardiac evaluations revealed atrial fibrillation and left atrial enlargement. He had successful recanalization after reperfusion therapies. Case 2: A 66-year-old woman with severe bilateral middle cerebral artery stenosis presented with right hemiparesis and dysarthria. MRI revealed the acute infarction in the left frontal and parietal lobe. In both cases, protein C activity was decreased which could be related to severe hyperthyroidism. They concomitantly had arterial lesions where blood stasis could occur. Severe hyperthyroidism which could evoke the decreasing of protein C activity could be responsible to develop acute ischemic stroke.

Non-occlusive mesenteric ischemia after trans-catheter aortic valve implantation with thyroid storm: A case report

Non-occlusive mesenteric ischemia (NOMI) is a rare but well-known life-threatening disease. However, reports on NOMI following trans-catheter aortic valve implantation (TAVI) are limited. This report presents a case of NOMI after trans-apical (TA) TAVI with thyroid storm. A 73-year-old man was admitted for a planned aortic valve surgery. Because he had severe aortic calcification and a right renal tumor that was suspected to be malignant, TA-TAVI was performed. At 61 h after TAVI, the patient complained of abdominal pain, and contrast-enhanced computed tomography showed ischemic necrosis of the cecum to the ascending colon. An ileocecal resection was performed emergently. He was extubated 61 h postoperatively, but severe delirium, high fever, and atrial fibrillation persisted. Due to a history of Basedow's disease, he was diagnosed with thyroid storm and treated with thiamazole and supportive care. The general status gradually improved, and he was transferred to the rehabilitation unit on the 17th postoperative day. We encountered a case of NOMI following TA-TAVI with a thyroid storm, which made it difficult to understand the patient's medical condition.

Learning objective

The occurrence of non-occlusive mesenteric ischemia after trans-catheter aortic valve implantation is rare but possible, and a thyroid storm could occur even after a less invasive surgery. It is important to perform postoperative management while considering the possible occurrence of this condition.

Thyroid storm induced by combined nivolumab and ipilimumab immunotherapy in advanced non-small cell lung cancer

Thyroid storm is a rare and life-threatening condition associated with excess thyroid hormones. Early detection of thyroid storm is the key to decreasing the morbidity and mortality associated with this condition. We present a rare case of thyroid storm induced by combination therapy with nivolumab and ipilimumab in a patient with advanced non-small cell lung cancer (NSCLC). Because of prominent hyperthyroidism with gastrointestinal symptoms and signs of heart failure, the patient was diagnosed with thyroid storm 3 weeks after initiating this combination immunotherapy. The patient had no history of thyroid disease but was positive for antithyroid antibodies. This case report suggests that thyroid function and symptoms of suspected thyroid storm should be evaluated routinely within 3 weeks from the initiation of therapy when combination therapy is administered in patients with NSCLC positive for antithyroid antibodies.

Interplay between cardiovascular and thyroid dysfunctions: A review of clinical implications and management strategies

Cardiovascular diseases (CVD) and thyroid dysfunction are two of the most prevailing disorders in the world that are closely interlinked. Actions of thyroid hormones are mediated via thyroid receptors present in the myocardium and the vascular tissue. Primary mechanism that links thyroid dysfunction with CVD is the modification of cardiovascular risk factors (dyslipidemia, blood pressure, coagulation parameters, etc.) resulting in endothelial and left ventricular systolic and diastolic dysfunction.

Both overt and subclinical hyperthyroidism and hypothyroidism may cause adverse alterations in cardiac function. Hyperthyroidism gives rise to palpitation, atrial fibrillation, systolic hypertension, and heart failure, whereas hypothyroidism increases diastolic hypertension, pericardial effusion, and the risk of ischemic heart disease via altering lipid and coagulation parameters. Early recognition and treatment of thyroid dysfunction may prevent adverse cardiovascular events in patients with or without pre-existing CVD.

Certain cardiac conditions and medications can cause alterations in thyroid function that may predispose an individual to higher morbidity and mortality. In certain situations, thyroid dysfunction treatment may have cardiovascular benefits. This study deals with the interplay between cardiovascular and thyroid dysfunctions associated with clinical implications and management strategies.

Anaesthetic implications of a case of hyperthyroidism detected during the closure of an atrial septal defect

A woman in her mid-20s who was clinically euthyroid presented with an ostium secondum atrial septal defect for closure. Preoperatively, heart rate ranged from 80 to 110 beats per minute. On the day of surgery, heart rate was 120 beats per minute, which settled after induction. During ultrasound guided central line access, a thyroid swelling was noticed. 20-30 min after commencement of the surgery, heart rate increased up to 130 beats per minute. Since other causes of tachycardia was ruled out, an intraoperative blood sample for thyroid function test was sent. Esmolol was kept ready in case the swelling turned out to be hyperfunctioning thyroid nodule. Post bypass, the patient again developed tachycardia. The thyroid function test showed elevated T3, T4 and a mildly elevated TSH (Thyroid stimulating hormone) value, consistent with an extrathyroid source. The patient is on long-term follow-up under an endocrinologist. Postoperatively, she is again euthyroid and heart rates have settled to less than 100 beats per minute.

Clinical Review and Update on the Management of Thyroid Storm

Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves' disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis. The purpose of this article is a clinical review of the various treatments and methodologies to achieve a euthyroid state in patients with thyroid storm prior to definitive therapy.

Continuous improvement of both hepatic and cardiac dysfunction by sequential plasma exchange in a patient with thyrotoxicosis and cardiogenic shock: a case report indicating the potential role of cardiohepatic interactions during thyroid storm

Background

Thyroid storm (TS) complicated by cardiogenic shock is associated with high mortality due to the high incidence of multiple organ failure. It is recommended that TS patients with hepatic failure undergo plasma exchange (PE) and receive optimal anti-hyperthyroid medications. However, the effect of PE on cardiac dysfunction in TS patients has been unclear.

Case summary

A 46-year-old woman was admitted to our hospital for dyspnoea and tachycardia. She was diagnosed with TS pursuant to Graves' disease complicated by acute decompensated heart failure (ADHF). Cardiac function was remarkably impaired [left ventricular ejection fraction (LVEF) = 15-20%], with rapid atrial fibrillation. Despite the management of both ADHF and hyperthyroidism, cardiogenic shock developed; therefore, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pumping (IABP) were initiated. Plasma exchange was performed after severe hepatic failure manifested on Day 2. After the first three PE treatments, cardiac and hepatic function improved immediately but deteriorated the next day. The improvement persisted after the fourth PE, and the patient was weaned from VA-ECMO and IABP on Days 10 and 11, respectively. She was discharged on Day 37, and her cardiac function was still normal 1.5 years later.

Discussion

In hyperthyroidism, severe hepatic dysfunction is more likely to occur in patients with acute ADHF than in those without it. Plasma exchange has the potential to improve not only hepatic but also cardiac dysfunction under optimal antithyroid treatment, especially in patients with TS complicated by severe hepatic dysfunction.

Efficacy of preoperative therapeutic plasma exchange in patients with hyperthyroidism and factors affecting the number of sessions

PURPOSE

Achieving preoperative euthyroidism in patients with hyperthyroidism for whom antithyroid drugs (ATDs) cannot be used for treatment is a serious clinical problem. We aimed to evaluate the effectiveness of therapeutic plasma exchange (TPE) in hyperthyroid patients scheduled for surgery and predictive factors for a high number of TPE sessions.

METHODS

We retrospectively analyzed the data of 21 patients with hyperthyroidism who were treated with TPE for preoperative euthyroidism in our institution. Pre- and post-TPE thyroid function tests were compared to assess efficacy. Binary logistic regression analysis was applied to determine predictors of patients requiring a high number of TPE sessions.

RESULTS

All patients (20 patients with Graves' disease and 1 patient with toxic multinodular goiter; 12 women and 9 men; mean age 35.71 ± 12.38 years) had severe hyperthyroidism before TPE. The changes before and after TPE in fT3, fT4, and TSH levels were statistically significant (p < 0.001, p < 0.001, p = 0.002, respectively). The median number of TPE sessions was 8 (range: 1-24). Levels of fT3 before TPE were significantly higher in patients for whom higher numbers of TPE sessions were required (≥8) (OR: 1.427, 95% CI: 1.038-1.961, p = 0.028). Receiver operating characteristic curve analysis revealed an optimum cut-off value of 12.8 pg/ml for fT3 before TPE (91% sensitivity, 80% specificity, area under the curve: 0.927).

CONCLUSION

TPE should be considered as an effective alternative treatment option that can be used to rapidly achieve euthyroidism before surgery when ATDs cannot be used. Pre-TPE fT3 levels of >12.8 pg/ml may be an independent factor predicting the need for higher numbers of TPE sessions (≥8).

Hemodynamic variation is a dominant contributing factor of Graves' hyperthyroidism complication: Heart failure and fatal liver dysfunction, a case report and analysis

Tachycardia and atrial fibrillation, early symptoms of hyperthyroidism indicate significant hemodynamic variation in cardiovascular system, if left untreated and further deterioration in hemodynamics can result in chronic heart failure and liver dysfunction even a fatal event. We describe a female patient of Graves' hyperthyroidism to present the continuum of the pathophysiology development of the disease, to highlight the hemodynamic variation is a dominant contributing factor of Graves' hyperthyroidism complication, we wish to emphasize cardiac manifestations in the setting of thyrotoxicosis should be treated promptly and aggressively.

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

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.

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.

Neurological and gastrointestinal symptoms as an initial presentation of pediatric thyroid storm: report of three cases

OBJECTIVES

Thyroid storm (TS) is a rare but life-threatening condition caused by decompensated hyperthyroidism. There is no consensus on how to diagnose pediatric TS. We report three pediatric cases of TS presenting with central nervous system (CNS) and gastrointestinal (GI) symptoms as the initial presentation of Graves' disease.

CASE PRESENTATION

They were previously healthy adolescents without family history of thyroid disease. CNS symptoms varied from agitation to coma. GI symptoms included abdominal pain, vomiting, and diarrhea. Their laboratory studies revealed thyrotoxicosis and positive result of thyroid-stimulating antibody (TSAb). They were admitted to the intensive care unit (ICU) and received the combination of an antithyroid drug, Lugol's solution, a beta antagonist, and hydrocortisone. The most severe case was a 13 year-old Japanese girl who presented with loss of consciousness and hemodynamic shock. She died after 5 days of intensive treatment.

CONCLUSIONS

Pediatricians should consider TS in the differential diagnosis when a patient exhibits both CNS and GI symptoms.

Postoperative thyroid storm after radical nephrectomy for renal cell carcinoma with inferior vena cava tumor thrombus

INTRODUCTION

Thyroid storm is a rare life-threating condition. We report a case of thyroid storm after radical nephrectomy for renal cell carcinoma with inferior vena cava tumor thrombus.

CASE PRESENTATION

A 76-year-old man with a left renal tumor and tumor thrombus extending into the inferior vena cava underwent left radical nephrectomy and thrombectomy. After the surgery, his postoperative course rapidly deteriorated, including central nervous system disturbance, fever, tachycardia, congestive heart failure, and hepatic manifestation. Thyroid function test revealed perioperative hyperthyroidism. Corticosteroids and inorganic iodide improved his condition, suggesting that he developed thyroid storm after surgery. He was discharged 5 months after surgery and has been free from disease recurrence for more than 2 years.

CONCLUSION

Thyroid storm after surgery is rare. However, this postoperative complication is important because it is fatal if not diagnosed and treated properly.

Getting around the gut: a unique management challenge of thyroid storm precipitated by amphetamine-associated duodenal ischaemia leading to compromised enteric absorption

Thyroid storm is a rare, life-threatening endocrine emergency with a high mortality rate of up to 30%. We present a unique management challenge of a critically ill patient who developed thyroid storm in the setting of a duodenal perforation from amphetamine-associated non-occlusive mesenteric ischaemia. The diagnosis of 'thyroid storm' was made based on clinical criteria and a Burch-Wartofsky score of 100. During emergent exploratory laparotomy, a 1 cm duodenal perforation with surrounding friable tissue was found and repaired. Intraoperatively, a nasogastric tube was guided distal to the area of perforation to allow for enteric administration of medications, which was critical in the setting of thyroid storm. Therapeutic plasma exchange achieved biochemical control of our patient's thyroid storm but ultimately did not prevent in-hospital mortality.

Targeted Temperature Management for In-hospital Cardiac Arrest Caused by Thyroid Storm: A Case Report

Background: Malignant ventricular arrhythmias caused by thyroid storm, such as ventricular tachycardia (VT) or ventricular fibrillation (VF), which are life-threatening, are rare. We report the case of a patient who suffered from cardiac arrest caused by thyroid storm and the rare VF; the patient showed a favorable neurologic outcome after receiving targeted temperature management (TTM) treatment by intravascular cooling measures.

Case presentation: A 24-year-old woman who had lost 20 kg in the preceding 2 months presented to the emergency department with diarrhea, vomiting, fever, and tachycardia. Thyroid function testing showed increased free triiodothyronine (FT3) and free thyroxine (FT4), decreased thyroid-stimulating hormone (TSH), and positive TSH-receptor antibody (TRAB). She was diagnosed with hyperthyroidism and had experienced sudden cardiac arrest (SCA) due to ventricular fibrillation (VF) caused by thyroid storm. The patient was performed with targeted temperature management (TTM) by intravascular cooling measures. Regular follow-up in the endocrinology department showed a good outcome.

Conclusions: Our case not only suggests a new method of cooling treatment for thyroid storm, but also provides evidence for the success of TTM on patients resuscitated from in-hospital cardiac arrest (IHCA) who remain comatose after return of spontaneous circulation (ROSC).

Preoperative Therapeutic Plasma Exchange and Surgical Treatment in Thyrotoxicosis Patients: A Single-Centre Retrospective Cohort Study

Context

Therapeutic plasma exchange (TPE) provides time for thyroidectomy in thyrotoxic patients.

Objective

TPE is indicated in cases where antithyroid medications cannot be used due to the side effects or attain no adequate hormonal suppression response at the highest dosage and in cases of rapid onset of clinical symptoms. This study presents the treatment results of patients who underwent TPE and were subsequently operated for thyrotoxicosis.

Design

The patients who underwent thyroidectomy and TPE between January 1999 and February 2019 were retrospectively analyzed.

Subjects and Methods

The files of 27 patients with thyrotoxicosis who performed TPE prior to surgery were analyzed in relation to the demographic and clinical features.

Results

We included 15 (55.6%) females, 12 (44.4%) males with a mean age of 44 (23-82) years. The pre-TPE mean free thyroxine (fT4) level was 12 (5-46) pmol/L while free tri-iodothyronine (fT3) level was 34 (17-141) pmol/L. The post-TPE fT4 level was 6 (3-10) pmol/L while the fT3 level was 21 (12-41). There was one case of an allergic reaction during the procedure. In the postoperative follow-up, there was transient hypocalcemia in 8 (29%) patients, permanent hypocalcemia in 1 (3.7%) patient, and surgical site infection in 1 (3.7%) patient.

Conclusion

Preoperative TPE is an alternative treatment option for thyrotoxic patients. This is an especially effective treatment for patients with inadequate response or adverse reaction to antithyroid drugs or patients who need urgent surgery for thyroid storm.

Relative Adrenocortical Insufficiency Following Radioactive Iodine Therapy for Graves' Disease: A Report of Two Cases

Introduction

In recent years, radioactive iodine (RAI) therapy has become a main choice for Graves' disease. The rapid release of thyroid hormones following RAI may on occasion trigger severe events, such as thyroid storm or heart block. This study presents two cases of possible acute adrenocortical insufficiency precipitated by radioiodine therapy.

Case Presentation

Two females aged 65 and 19 years with long-standing Graves' disease underwent radioiodine treatment at our clinical center. Both patients suffered nausea, fatigue, aggravated palpitation, and relative hypotension thereafter. Laboratory data showed severe thyrotoxicosis with free thyroxine higher than three times the upper limit, while basal serum cortisol (8 AM) was below the lower limit (5.08 μg/dL and 2.08 μg/dL respectively) under stress, indicating a potential relative adrenocortical insufficiency. There was then full recovery after adequate hydrocortisone therapy. As thyrotoxicosis resolved, the levels of basal cortisol were subsequently raised to normal.

Conclusion

Post-RAI adrenocortical insufficiency might occur in patients with severe Graves' disease. Basal serum cortisol might be a cost-effective parameter for the identification of potential patients.