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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 ) 23 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 24 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 28