Download Thyroid Storm

Thyrotoxic Crisis
R4 조경민 / Prof. 우정택
Review
Thyroid storm의 진단 및 증상
Thyroid Storm & Unusual Case
Treatment
Hyperthyroidism
Over production
from the thyroid gland
Thyrotoxicosis
Thyroid storm
Excessive thyroid
hormone d/t any cause
Extreme manifestation of
thyrotoxicosis
Thyroid storm:
Incidence : Less than 10% of hospitalized thyrotoxicosis
Mortality: 20-30%
3
유발 인자
Surgery
Noncompliance to
antithyroid medications
Infection
Trauma
Acute
Iodine
load
Wilkinson JN Anaesthesia 2008;63:1001–1005
Thyroid storm certain factor  unclear
Responsiveness to catecholamines
Serum Thyroid Hormone Levels
Cellular responses
to thyroid hormone
Rev Endocr Metab Disord. 2003;4(2):129.
Thyroid storm
Typically;
Thyroid hormone excess is not
profound
Clinical Finding
Agitation
Anxiety
Delirium
Nausea, Vomiting, Diarrhea
Psychosis,
Stupor,
Coma
Hypotension,
Cardiacarrhythmia
Various Unusual Presentations of Thyroid Storm
Arrhythmias
Complete Heart block
Heart failure
Resuscitation 2007;73:485–490.
South Med J 2004;97:604–607.
Coma, Status epilepticus
Stroke , Cerebral Infarction
Br J Clin Pract 1984;41:671–673.
Acute liver Failure
Cholestatic Jaundice
J Clin Gastroenterol 1999; 29:318–321.
Rhabdomyolysis
Am J Med 1984; 77:733–735.
DIAGNOSIS
based upon clinical findings
Clinical
Finding
Cardiovascular symptoms
Tachycardia to rates: exceed 140
beats/minute , Hypotension
Agitation, Anxiety, Delirium
Psychosis, Stupor
Cardiac arrhythmia, Congestive Heart Failure.
Lab finding
Nausea, Vomiting, Diarrhea,
Hypercalcemia,
Abdominal Pain,
Abnormal Liver Function, Leukocytosis
Diagnostic Criteria For Thyroid Storm
In 1993, Burch and Wartofsky
(scoring system)
Heart Failure
Cardiovascular
Dysfunction
Thermo-regulatory
Dysfuction
Precipitant History
Gastrointestinal-
Central Nervous
Hepatic dysfunction
System Effects
Diagnostic Criteria For thyroid Storm
In 1993, Burch and Wartofsky
introduced a scoring system
Maximal possible score : 130
> 45
highly suggestive of
thyroid storm
25 - 44
supports the diagnosis
< 25
thyroid storm unlikely.
Endocrinol Metab Clin North Am 1993; 22:263
Ventricular
Tachycardia
Ventricular
Dysfunction
Diabetic
Ketoacidosis
4 case
Various Unusual Presentations of Thyroid Storm
1
44-year-old woman
chest pain and dyspnea
CK :170 U/l
CK-MB :17.9μG/l.
troponin T :0.18 μG/l
EKG: elevation of the ST segment in V2
Leucocytes & C-reactive protein
Neth Heart J. 2011 May 3
1 Severe transient left ventricular dysfunction
induced by thyrotoxicosis
TakoTsubo
Normal
Akinetic wall motion abnormality in
posterolateral & diaphragmatic wall
Free of symptom
Six days after treatment
with propylthiouracil and propanolol
Neth Heart J. 2011 May 3
2
34-year-old woman
sudden loss of consciousness
cyanotic and unresponsive.
Pupils were fixed and dilated.
No spontaneous respiration.
•Cardiac ultrasound
:no chamber dilation
•Ejection fraction : 80%.
Southern Medical Journal • Volume 97, Number 6, June 2004
2
Thyroid Storm and Ventricular Tachycardia
TSH : 0.001 mIU/mL , Free T4 :4.22 ng/dL, T3 :125 ng/dL
Thyroid Storm
propylthiouracil , propranolol , hydrocortisone, Acetaminophen, Lugol solution
Arrhythmia 호전
Coma & Died after 16 days of hospital stay due to pneumonia.
Arrhythmias : supraventricular, with atrial fibrillation (m/c)
Ventricular premature contractions and ventricular fibrillation are rare
3
Thyroid Storm
with Multiorgan Failure
35-year-old patient with a history of Graves’ disease
(Thyroid storm at 2 weeks postpartum)
Drowsy, confused
THYROID Volume 20, Number 3, 2010
3
white cell count 8.24x109/L
hemoglobin 13.3 g/dL
free triiodothyronine 12.4pmol/L
(normal range 4.3–8.3 pmol/L)
platelet count 178x109/L
thyroid stimulating hormone < 0.02 mIU/L
(0.45–4.5mIU/L)
sodium 134mmol/L
Thyroidstimulating hormone receptor
antibody :positive (6.8 IU/L)
potassium 5.0mmol/L
creatinine 69 mmol/L
free thyroxine 34.1 pmol/L
(normal range 10.0–23.0 pmol/L)
Antithyroglobulin & antithyroid peroxidase
antibodiespropylthiouracil
: negative
IV dexamethasone+
+
sodium iodide
Procalcitonin, a propeptide of calcitonin
produced in the C cells of the thyroid gland :
3.23 mg/L (normal range <0.50 mg/L)
lactate 6.6mmol/L
증상 호전 후, 퇴원
ICU
Acute liver failure
Acute kidney injury
Gastrointestinal Bleeding
Disseminated Intravascular
Coagulation
Hematuria
THYROID Volume 20, Number 3, 2010
4
59-year-old woman with no history of
diabetes mellitus or thyroid disease
Nausea, Vomiting and Diarrhea for 2
days
Disturbance Of Consciousness
Fever, and Tachycardia
Thyroid Research 2011, 4:8
4
Elevation of random
blood glucose
Elevation of glycosylated
Hemoglobin (HgA1c)
Positive of
Urine ketone
Metabolic acidosis
Treatment with Insulin & Adequate Fluid Replacement
T3 and FT4 : 증가
Disturbance of Consciousness
TSH: 감소 TR Ab (+)
& Tachycardia  Persistent
Thyroid Storm Score of Burch & Wartofsky :
- 75/140
Thiamazole, Potassium Iodide and Propranolol
 Immediate Relief of Tachycardia
Thyroid Research 2011, 4:8
TREATMENT
Thyroid Storm
TREATMENT
Removal of excess circulating hormone
Inhibition of new hormone
Inhibition of T4-to-T3 conversion
Inhibition of hormone release
22
Beta-blocker:
control the symptoms
Thionamide:
TREATMENT
block new hormone synthesis
Iodine solution:
block the release of thyroid hormone
Iodinated radiocontrast agent:
inhibit the peripheral conversion of T4 to T3
Glucocorticoids:
reduce T4-to-T3 conversion, promote vasomotor stability
Acetoaminophen is preferable to aspirin
(serum free T4 and T3 by interfering with their protein binding
)
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TREATMENT
beta-blocker:
• Intravenously: 0.5 to 1 mg over 10 minutes followed by 1 to 2 mg
• over 10 minute
• Orally: 60 to 80 mg orally every four to six hours
• Propylthiouracil & Methimazole: PTU for the acute treatment of lifethreatening thyroid storm in an intensive care unit (ICU) setting
Thionamide
• PTU, but not Methimazole, blocks T4 to T3 conversion
• (over the first few hours after administration)
• PTU : 200 mg of every four hours
• Methimazole : 20 mg every four to six hours
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TREATMENT
• Iodine blocks the release of T4 and T3 from the gland within hours
Iodine
• The administration of iodine should be delayed for at least one hour
• after thionamide administration
• Oral doses are Lugol's solution, 10 drops tid
Iodinated
radiocontrast
agents
Glucocorticoids
• Potent inhibitors of T4 to T3 conversion
• Blocking thyroid hormone release
• Reduce T4 to T3 conversion
• Direct effect on the underlying autoimmune process
25
Glucocorticoids
Thyrotoxicosis is associated
with subtle impairment of
adrenocortical reserve
Glucocorticoid treat potentially associated limited adrenal reserve
European Journal of Endocrinology 2000;142: 231–235
Plasmapheresis has been tried when traditional therapy has not been successful
Lithium has also been given to acutely block the release of thyroid hormone.
However, its renal and neurologic toxicity limit its utility
27
Long-term management
PTU: if given, should be switched Methimazole
(because :methimazole’s better safety profile and better compliance rates)
Definitive therapy with radioactive iodine or thyroidectomy :
prevent a recurrence of severe thyrotoxicosis
Surgery is an option for patients with hyperthyroidism due to a very large or
obstructive goiter
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