Hypoglycemic coma masquerading thyrotoxic storm

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.

Fulminant hepatitis and elevated levels of sIL-2R in thyroid storm

SUMMARY

We report the case of a 48-year-old man with thyroid storm associated with fulminant hepatitis and elevated levels of soluble interleukin-2 receptor (sIL-2R). Fatigue, low-grade fever, shortness of breath, and weight loss developed over several months. The patient was admitted to the hospital because of tachycardia-induced heart failure and liver dysfunction. Graves' disease with heart failure was diagnosed. He was treated with methimazole, inorganic iodide, and a β-blocker. On the day after admission, he became unconscious with a high fever and was transferred to the intensive care unit. Cardiogenic shock with atrial flutter was treated with intra-aortic balloon pumping and cardioversion. Hyperthyroidism decreased over 10 days, but hepatic failure developed. He was diagnosed with thyroid storm accompanied by fulminant hepatitis. Laboratory investigations revealed elevated levels of sIL-2R (9770 U/mL). The fulminant hepatitis was refractory to plasma exchange and plasma filtration with dialysis, and no donors for liver transplantation were available. He died of hemoperitoneum and gastrointestinal hemorrhage due to fulminant hepatitis 62 days after admission. Elevated circulating levels of sIL-2R might be a marker of poor prognosis in thyroid storm with fulminant hepatitis.

LEARNING POINTS

The prognosis of thyroid storm when fulminant hepatitis occurs is poor. Liver transplantation is the preferred treatment for fulminant hepatitis induced by thyroid storm refractory to plasma exchange. Elevated levels of soluble interleukin-2 receptor might be a marker of poor prognosis in patients with thyroid storm.

Coma in Thyroid Storm: Review of Aggregated English-Language Case Reports

CONTEXT

Coma is a serious manifestation of thyroid storm (TS) about which little is known.

OBJECTIVE

To describe the features, duration, treatment response, and prognosis of coma in the setting of TS.

DESIGN

Aggregate analysis of individual English-language case reports of coma in the setting of TS from 1935 to January 2019.

SETTING

Hospitals.

PATIENTS

Sixty-five cases were identified, 29 from case reports and 36 from case series.

INTERVENTIONS

Antithyroid drugs, corticosteroids, beta-blockers, iodine, intubation, plasmapheresis, antibiotics, thyroidectomy, radioiodine, dialysis, and l-carnitine.

MAIN OUTCOME MEASURES

Awakening and death rates overall and in relation to administered treatments, day of coma presentation, and time from coma onset; symptoms associated with coma; TS and coma scales; thyroid and cerebrospinal laboratory tests; electroencephalogram; brain imaging; and autopsy results.

RESULTS

Mortality was 38% in the setting of TS-related coma, 11% during the years 1978 to 2019 compared with 70% for 1935 to 1977. Both awakening and death commonly occurred within the first 2 days of coma onset. Reduction in total and free T4 values, and possibly also total T3 value, correlated with awakening from coma. Lower death rates were associated with use of antithyroid drugs, corticosteroids, beta-blockers, and intubation. Plasmapheresis was associated with awakening in 67% of cases but not with lower death rates.

CONCLUSIONS

Prognosis of coma associated with TS remains poor. Current guidelines for the early use of plasmapheresis in unresolving TS are advocated and should be considered urgently at the point of confusion or delirium in an effort to abort coma.

Thyrotoxic Storm

Thyrotoxic storm is a syndrome of exaggerated thyrotoxicosis with systemic decompensation seen in 1-2% of hospital admissions for thyrotoxicosis. The diagnosis is based on recognition of typical cardinal manifestations, but even when diagnosed and treated, mortality rates are high. Results of thyroid function tests may be no more abnormal than those seen in uncomplicated thyrotoxicosis. Often, there is a history of partially treated thyrotoxicosis, and/or decompensation related to a precipitating event such as infection, stroke, pulmonary embolism, or radioiodine therapy. Treatment must be aggressive and includes volume repletion with i.v. glucose and saline, and pressor agents may be needed. Patients belong in an intensive care unit, with a cooling blanket for hyperpyrexia. Appropriate cardiac medications are employed to control ventricular rate in those with atrial fibrillation. The thyroid is blocked by large doses of antithyroid agent. In patients unable to swallow, tablets can be crushed and given by nasogastric tube or per rectum. After antithyroid drugs are started, stable iodine as Lugol's solution is given to block further hormone release from the gland. Sodium ipodate can be used instead of iodine and has the advantage of inhibiting conversion of T4 to T3. In severe cases, thyroid hormone may be removed from the circulation by peritoneal dialysis or plasmapheresis, and cholestyramine resin may be used to bind T4 and T3 within the gastrointestinal tract. β-adrenergic antagonists such as propranolol are given, or the very short-acting β-adrenergic blocker, esmolol, has also been used with success. A Swan-Ganz catheter is used to monitor central hemodynamics, especially in patients receiving high-dose propranolol, pressors, digoxin, diuretics, and fluids. Large doses of dexamethasone have been given based on presumed increased glucocorticoid requirements in thyrotoxicosis and because adrenal reserve may be reduced. Therapy must be continued until a normal metabolic state is achieved, at which time iodine is progressively withdrawn and plans made for definitive treatment.

Electroencephalography of encephalopathy in patients with endocrine and metabolic disorders

Patients with acute alteration in mental status from encephalopathy because of underlying metabolic-toxic or endocrine abnormalities are frequently seen in the acute hospital setting. A rapid diagnosis and correction of the underlying cause is essential as a prolonged state of encephalopathy portends a poor outcome. Correct diagnosis and management remain challenging because several encephalopathies may present similarly, and further laboratory, imaging, or other testing may not always reveal the underlying cause. EEG provides rapid additional information on the encephalopathic patient. It may help establish the diagnosis and is indispensable for identifying nonconvulsive status epilepticus, an important possible complication in this context. The EEG may assist the clinician in gauging the severity of brain dysfunction and may aid in predicting outcome. This review summarizes the current knowledge on EEG findings in selected metabolic and endocrine causes of encephalopathy and highlights distinct EEG features associated with particular etiologies.

Severe hypoglycemia accompanied with thyroid crisis

We report a 32-year-old Japanese women with severe hypoglycemia accompanied with thyroid crisis. She complained of dyspnea, general fatigue, and leg edema. She was diagnosed with hyperthyroidism with congestive heart failure and liver dysfunction. Soon after admission, sudden cardiopulmonary arrest occurred. She was then transferred to the intensive care unit. Her serum glucose level was 7 mg/dl. Intravenous glucose, hydrocortisone, diuretics, and continuous hemodiafiltration (CHDF) saved her. We considered that hypoglycemia occurred due to heart failure and liver dysfunction due to thyroid crisis.

Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis

Thyroid storm is a rare, but critical, illness that can lead to multiorgan failure and carries a high death rate. The following case series describes two adult men with Graves' disease who presented in thyroid storm and either failed or could not tolerate conventional medical management. However, both patients responded well to plasmapheresis, which resulted in clinical and biochemical stabilisation of their disease processes. The treatment option of plasmapheresis should be considered as a stabilising measure, especially when patients have failed or cannot tolerate conventional therapy. Plasmapheresis leads to amelioration of symptoms and a significant decline in thyroid hormone levels, providing a window to treat definitively with thyroidectomy.

Hypoglycemic encephalopathy: a case series and literature review on outcome determination

Data on clinical long-term outcome after the acute phase of hypoglycemic encephalopathy (HE) using validated outcome scales is currently unavailable. Here we report the results of a systematic literature search for studies on HE and data on long-term outcome in patients with HE admitted to three Charité hospitals between January 2005 and July 2010. HE was defined as coma/stupor and blood glucose levels <50 mg/dl on admission, persistence of coma/stupor for ≥24 h despite normalization of blood glucose levels, and exclusion of any other cause of coma/stupor. Outcome was assessed using the modified Rankin scale (mRS), Glasgow Outcome Scale (GOS), and Barthel index (BI). Fifteen patients were included, with a mean age of 60 years (range 29-79). Two were lost to follow-up. Of the remaining 13 patients, six had died (46 %). In the seven survivors, the median mRS score was 0 (range 0-5), median GOS score was 5 (range 2-5), and median BI was 100 (range 0-100). MRIs made in the acute phase were available for three patients and revealed no obvious relation between lesion size or pattern and clinical outcome. To our knowledge, this is the first case series using validated clinical scoring systems to determine clinical long-term outcome after HE. The results suggest that mortality is high, but long-term survival with little or no disability is possible and can be observed in the majority of survivors. Risk of death or poor outcome does not seem to be related to MRI features in the acute phase but rather to other presumably medical factors.

Hypoglycemia revisited in the acute care setting

Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

A patient with thyroid storm presenting with apathetic thyrotoxicosis and features of meningoencephalitis

BACKGROUND

Apathetic thyrotoxicosis is distinctly unusual in thyroid storm and features of meningoencephalitis are very rare. Here we present such a patient.

PATIENT FINDINGS

The patient was a 67-year-old Chinese woman who presented with acute generalized weakness, decreased mentation, fever, and rapid deterioration to coma, accompanied by meningism, initially mimicking meningoencephalitis. Further investigations excluded intracranial lesions. Laboratory findings were consistent with Graves' thyrotoxicosis. She was treated for thyroid storm with antithyroid drugs, Lugol's iodine solution, and other supportive management. Subsequently, her level of consciousness returned to normal and neurological signs resolved.

SUMMARY

We report a patient with thyroid storm with an apathetic presentation, manifesting as coma with meningism, that mimicked meningoencephalitis. These resolved after treatment for thyroid storm was instituted.

CONCLUSIONS

Apathetic thyrotoxicosis is a rare presentation of thyroid storm. Early recognition and treatment is essential for reducing its morbidity and mortality.

A 3-year-old girl with Graves' disease with hypoglycemia following transient adrenal hyporesponsiveness

A 3-year-old girl with Graves' disease developed a generalized convulsion as a result of hypoglycemia (25 mg/dL). At the time of the hypoglycemic seizure, her plasma adrenocorticotropin (ACTH) level (1460 pg/mL) was extremely high, but her serum cortisol level (28.4 microg/dL) was relatively low given the severe stress. The cortisol-releasing hormone (CRH) provocation test done after thyroid function had improved revealed normal ACTH and cortisol responses. Since there was no other cause of hypoglycemia, such as hyperinsulinemia, long-term starvation, suddenly advanced emaciation, or prolonged fasting, it was suspected that the transient adrenal hyporesponsiveness was the main cause of hypoglycemia.

Thyroid storm with multiorgan failure

BACKGROUND

Thyroid storm is a rare and potentially fatal condition. Various unusual presentations in patients with thyroid storm have been described but multiorgan dysfunction is uncommonly seen.

SUMMARY

We describe a 35-year-old patient with a history of Graves' disease who was diagnosed with thyroid storm at 2 weeks postpartum. This was complicated by acute liver failure, acute kidney injury, severe lactic acidosis, disseminated intravascular coagulation, and heart failure with acute pulmonary edema. The multiorgan dysfunction was reversed by prompt institution of antithyroid drugs and supportive management in the intensive care unit.

CONCLUSION

Thyroid storm is a medical emergency. One of the challenges lies in recognizing its varied presentations. Early diagnosis and appropriate treatment is important to prevent the catastrophic outcomes associated with this condition.

A case of atypical thyroid storm with hypoglycemia and lactic acidosis

We describe herein a case of thyroid storm with hypoglycemia and lactic acidosis-a rare complication of thyroid storm. The patient was a 50-year-old Japanese woman who suffered cardiopulmonary arrest an hour after hospitalization. Analysis of a blood sample obtained before her cardiopulmonary arrest yielded surprising results: Her plasma glucose level was 14 mg/dL and her lactic acid concentration had increased to 6.238 mM. Thus, if atypical thyroid storm presents with normothermic hypoglycemia, and lactic acidosis, we believe it is necessary to consider a diagnosis of thyroid storm earlier, because this condition requires emergency treatment. Moreover, it is very important to apply standard principles in the treatment of atypical cases of thyroid storm.

Severe starvation hypoglycemia and congestive heart failure induced by thyroid crisis, with accidentally induced severe liver dysfunction and disseminated intravascular coagulation

A 69-year-old woman caught a cold resulting in nausea, vomiting, diarrhea and severe anorexia. Then she suffered progressively from dyspnea and leg edema, and finally became delirious. On admission severe hypoglycemia, hypothermia, marked tachycardia, generalized edema, mild jaundice and cachexy were noted. EKG showed atrial fibrillation. A chest X-ray, chest CT and echocardiography showed congestive heart failure. Therapeutic use of diuretics induced shock leading to serious liver dysfunction and disseminated intravascular coagulation. However, combined therapy by intravenous glucose, digitalis, diuretics, anti-fibrinolytic drug and hydrocortisone were effective. Addition of antithyroid therapy brought a further favorable outcome.

Thyroid storm as precipitating factor in onset of coma in an elderly woman: case report and literature review

Thyroid storm is an uncommon but life-threatening manifestation of hyperthyroidism which, unless appropriately treated by combined therapy, causes 30-60% of deaths in hospitalized patients. Mental deterioration leading to apathy and eventually coma is a rare clinical presentation of this pathology, frequently observed in the elderly. We present the case of a 77-year-old hypertensive woman who was hospitalized for fast onset of coma, probably due to the unusual combination of a hypernatremic hyperosmolar state and an unexpected thyroid storm (TS). Although not definitely ascertained, the possible etiology was the hyperthyroid phase of chronic autoimmune thyreopathy (Hashitoxicosis). Notably, the significant adjunctive role of thyroid hyperfunction in the pathogenesis of coma was confirmed by the fact that, although metabolic abnormalities were overcome, complete and satisfactory recovery of the patient's mental and physical condition occurred only with normalization of thyroid hormones by antithyroid treatment. Our case highlights the importance of properly evaluating thyroid function in elderly patients who show a sudden progressive impairment in their mental condition, for early detection of potentially fatal conditions such as thyroid storm or myxedematous coma.