Download Hyperthyroidism and Thyroid Storm

Hyperthyroidism and Thyroid
Storm
Jeffrey S. Freeman DO FACOI FNLA
Chairman Division of Endocrinology and
Metabolism
Philadelphia College of Osteopathic Medicine
Who is at risk for hyperthyroid?
• Individuals with
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Diffuse or Nodular Goiters
Type 1 diabetes (also, other endocrine and AI diseases)
Family history of hyper/hypo
Medications
•
•
•
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•
Amiodarone
Alpha-interferon
Interleukin-2
Lithium
Iodide
Iodinated contrast agents
– Only for those with preexisting
Symptoms to consider…
• Nervousness (99%)
• Increased sweating
(91%)
• Palpitations (89%)
• Tachycardia (82%)
• Heat intolerance (89%)
• Fatigue (88%)
• Weight loss (85%)
• Shortness of breath
(75%)
• Weakness (70%)
• Leg swelling (65%)
• Eye symptoms (54%)
• Hyperdefication (33%)
• Menstrual irregularity
(22%)
• Emotional lability (3060%)
Physical Exam findings
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Tachycardia (100%)
Goiter (100%)
Skin changes (97%)
Tremor (97%)
Bruit (77%)
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•
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•
Eye Signs (30-45%)
Atrial fibrillation (10%)
Splenomegaly (10%)
Gynecomastia (10%)
How do you diagnose?
• Order Serum TSH
– Low: free T4 or free T4
index
• If not elevated, order total
T3 or free T3
• Radioiodine uptake
• Thyroid scan
• Radioisotope studies
contraindicated…
– Blood tests:
• TSH-receptor antibodies
• Thyroid-stimulating
immunoglobulins
• Thyroid-peroxidase
antibodies
• Thyroglobulin
• HCG
• Sed rate
– Color Doppler US
– Whole body radioiodine
scan
Lab studies--indications
• TSH—suspected hyperthyroidism
– Free thyroxine (FT4)—suppressed TSH
– Free triiodothyronine (FT3) --suppressed TSH, normal FT4
• Thyroglobulin --suspected thyroiditis
• Erythrocyte sed rate ESR--suspected subacute thyroiditis
• TSH-receptor antibodies--euthyroid Graves ophthalmopathy
– assess remission with antithyroid drug Rx in Graves disease;
– assess neonatal risk in pregnant patients with Graves disease
• Thyroid peroxidase antibodies--confirm Hashimoto thyroiditis or
autoimmune thyroid disease
– assess risk for Rx-induced thyroid dysfunction and postpartum thyroiditis
RAIU--confirmed biochemical thyrotoxicosis, if cause unclear
Thyroid scan--confirmed biochemical thyrotoxicosis, if cause unclear
Whole body scan--suspected struma ovarii
Color Doppler US--type I vs. type II amiodarone-induced thyrotoxicosis
• Human chorionic gonadotropin HCG--choriocarcinoma
Alternative Explanations
• Infection
• Sepsis
• Anxiety
• Depression
• Chronic Fatigue Syndrome
• Atrial fibrillation of other causes
• Pheochromocytoma
TSH usually distinguishes these from hyperthyroidism
• BUT Serum TSH is low in:
– pregnancy, hyperemesis gravidarum;
– euthyroid sick syndrome;
– central hypothyroidism (with glucocorticoids, dopamine,
heparin)
What non-drug therapies?
• Until thyroid disease is adequately controlled
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Avoid heavy physical exertion
Reduce/eliminate caffeine intake
Ovoid OTC decongestants and cold remedies
Discontinue smoking
Avoid exogenous sources of iodine
Choosing drug therapies
• Beta-adrenergic blockade: symptomatic hyperthyroidism of
any cause
– Propranolol, atenolol, metoprolol, nadolol
• Side effects: CHF + asthma exacerbations
• Antithyroid medications: inhibits thyroid hormone
synthesis, thus lower thyroid hormone
– Methimazole: preferred
– Propylthiouracil: alternative
• If 1st trimester of pregnancy, if MZ allergy, thyroid storm
– Side effects: beware LIVER FAILURE, agranulocytosis in 0.2-0.4%
– Use: Graves, toxic multinodular goiter, toxic adenoma
– Don’t use for: low RAIU, hyperthyroidism
Ancillary Therapy
•
Potassium iodine : acutely reduces thyroid hormone release
– Use before thyroidectomy for Graves
– Don’t use before radioactive iodine therapy
•
Lithium: reduces thyroid hormone release
•
Cholestyramine: binds thyroid hormone in intestines
•
Nonsteroidal anti-inflammatory: treats subacute thyroiditis
•
Glucocorticoids: for severe subacute thyroiditis
When do you consider I-131?
• Graves disease
– Achieves remission in 90%
– Good choice if no remission with antithyroid
medications
• Side effects of I-131
– Hypothyroidism: eventually
– Sialadenitis: due to uptake by salivary glands (can be
quite painful)
– Worsening of orbitopathy
– Possible small increase in thyroid cancer
When should you consider I-131?
• Toxic multinodular goiters & toxic adenomas
– Pretreat with beta-adrenergic blockade and/or
– Methimazole: if very symptomatic or free T4 or FT4I
levels exceed upper limit more than 2x
• D/C Methimazole at least 7 days before I-131
• Propylthiouracil use may also apply
• Side effects of I-131 (not in pregnancy)
– Hypothyroidism: 50-70%
– Worsened symptoms in first 2 weeks from thyroid
hormone increase
– Thyroid storm, if severely hyperthyroid
When thyroidectomy?
• Most often recommended for…
Those who can’t tolerate or refuse alternative forms
of RX
– Pregnancy
– Patients who don’t achieve remission with
antithyroid RX
– Unable to perform I131 therapy do to
exopthalmus
Antithyroid medication monitoring
– Agranulocytosis, liver injury, vasculitis: discontinue
– Fever or pharyngitis: repeat CBC with differential WBC
– Symptoms of liver injury: order liver profile
Once symptoms resolved + results in reference range…
• Discontinue β-adrenergic blocker + reduce antithyroid Rx
• Continue clinical and lab assessments every 3–6 months
After 12-18 months reduced dose + normal TSH: ? Remission
– Taper or stop antithyroid Rx
– Measure TRAb: normal = greater likelihood remission
No remission: consider I-131 or surgery
Case
• 57 y/o female presents to the ER with anxiety, disruptive,
nervousness, SOB. She notes exacerbation of these symptoms
over the course of a month. She is currently too weak to walk
up steps with proximal muscle weakness.
• PMH: Grave’s disease treated with Methimazole 20 mg/daily.
• PE: Temp: 101.2 b/l proptosis, conjunctival injection, neck b/l
thyroid enlargement (with bruits) firm to palpation, HR: 140
(regular), coarse systolic murmur, lungs CTA, abdomen flat.
Integument smooth in texture and warm in temperature.
Reflexes: brachioradialis 3+/4+
• Labs: ultrasensitive TSH <0.01 mg, FreeT4 6.8, WC 12,000, LFT:
normal,
What is thyroid storm?
• Acute, life-threatening exacerbation of
thyrotoxicosis
• After surgery for thyroidectomy? Infection?
Recognizing Thyroid Storm
Thyroid crisis: exaggerated manifestations of
thyrotoxicosis
– Unrecognized/untreated thyrotoxicosis + precipitating
event (infection, trauma)
– Radioiodine therapy may precipitate
– Dx: often based on suspicious, non-specific clinical
findings
• Cardinal manifestations: fever >102 fever
• Other features: tachycardia, tachypnea; nausea/vomiting,
diarrhea, CNS manifestations, anemia, hyperglycemia
• Elevated serum total, free T4 and T3 levels; undetectable
serum TSH levels
Use Thyroid Scoring System
Thyroid Storm Scoring System
Fever ° F
Score
99–99.9
5
99–109
5
100–100.9
10
110–119
10
N, V, D, Pain
10
101-101.9
15
120–129
15
Jaundice
20
102-102.9
20
130–139
20
Precipitant history
103-103.9
25
≥140
25
Absent
0
>104
30
Atrial fibrillation
10
Present
10
GI signs
Absent
Cardiac–CHF
CNS agitation
Absent 0
Cardiac–pulse, bpm
0
Absent
0
5
Mild
10
Mild (edema)
Moderate
20
Moderate (rales)
10
Severe
30
Severe (pulm
edema)
15
Total Score
<25= unlikely
25-44= suggestive
>45= likely
0
How does a clinician treat?
1. Decrease thyroid hormone synthesis
– Propylthiouracil or methimazole
2. Inhibit thyroid hormone release
– Sodium iodide (IV) or potassium iodide (oral) (not before blocked)
3. Reduce heart rate
– β-blocker (esmolol, metoprolol, propranolol) or diltiazem
4. Support circulation
• Glucocorticoids in stress doses
• Fluids (IV), oxygen, cooling
5. Treat precipitating cause
6. NO ASPIRIN!!
When should patients be hospitalized?
• When thyroid storm present, impending, or suspected
– Prognosis with aggressive therapy  ≈20% mortality (was once 100%)
– Dx usually based on suspicious, nonspecific findings
– Do not wait for test results on serum TSH levels: delays potentially lifesaving
therapy
– Also, TSH levels don’t reliably distinguish thyroid storm from uncomplicated
thyrotoxicosis
Questions?