Hyperthyroidism

Endocrine Regulation on Bone by Thyroid

BACKGROUND

As an endocrine organ, the thyroid acts on the entire body by secreting a series of hormones, and bone is one of the main target organs of the thyroid.

SUMMARY

This review highlights the roles of thyroid hormones and thyroid diseases in bone homeostasis.

CONCLUSION

Thyroid hormones play significant roles in the growth and development of bone, and imbalance of thyroid hormones can impair bone homeostasis.

Hyperthyroidism and thyrotoxicosis

Hyperthyroidism and thyrotoxicosis are hypermetabolic conditions that cause significant morbidity and mortality. The diagnosis can be difficult because symptoms can mimic many other disease states leading to inaccurate or untimely diagnoses and management. Thyroid storm is the most severe form of thyrotoxicosis, hallmarked by altered sensorium, and, if untreated, is associated with significant mortality. Thyroid storm should be considered in the differential of any patient presenting with altered mental status. The emergency medicine physician who can rapidly recognize thyrotoxicosis, identify the precipitating event, appropriately and comprehensively begin medical management, and facilitate disposition will undoubtedly save a life.

Clinical concepts on thyroid emergencies

OBJECTIVE

Thyroid-related emergencies are caused by overt dysfunction of the gland which are so severe that require admission to intensive care units (ICU) frequently. Nonetheless, in the ICU setting, it is crucial to differentiate patients with non-thyroidal illness and alterations in thyroid function tests from those with intrinsic thyroid disease. This review presents and discusses the main etiopathogenetical and clinical aspects of hypothyroid coma (HC) and thyrotoxic storm (TS), including therapeutic strategy flow-charts. Furthermore, a special chapter is dedicated to the approach to massive goiter, which represents a surgical thyroid emergency.

DATA SOURCE

We searched the electronic MEDLINE database on September 2013. Data Selection and Data Extraction: Reviews, original articles, and case reports on "myxedematous coma," "HC," "thyroid storm," "TS," "massive goiter," "huge goiter," "prevalence," "etiology," "diagnosis," "therapy," and "prognosis" were selected.

DATA SYNTHESIS AND CONCLUSION

Severe excess or defect of thyroid hormone is rare conditions, which jeopardize the life of patients in most cases. Both HC and TS are triggered by precipitating factors, which occur in patients with severe hypothyroidism or thyrotoxicosis, respectively. The pillars of HC therapy are high-dose l-thyroxine and/or tri-iodothyroinine; i.v. glucocorticoids; treatment of hydro-electrolyte imbalance (mainly, hyponatraemia); treatment of hypothermia; often, endotracheal intubation and assisted mechanic ventilation are needed. Therapy of TS is based on beta-blockers, thyrostatics, and i.v. glucocorticoids; eventually, high-dose of iodide compounds or lithium carbonate may be of benefit. Surgery represents the gold standard treatment in patients with euthyroid massive nodular goiter, although new techniques - e.g., percutaneous laser ablation - are helpful in subjects at high surgical risk or refusing operation.

Management of severe thyrotoxicosis when the gastrointestinal tract is compromised

BACKGROUND

The management of patients with severe thyrotoxicosis in the absence of a functional gastrointestinal tract represents an uncommon but significant clinical challenge associated with a high mortality rate. This article offers a literature review and discussion of the available management options in this setting.

SUMMARY

Treatment of severe thyrotoxicosis in patients unable to ingest medications by the oral route should focus on normalization of thyroid hormone levels utilizing conventional medical therapy for thyrotoxicosis, administered via non-oral routes. This includes thionamides, beta-blockers, iodine containing solutions, and glucocorticoids. When conventional medical therapy fails, plasmapheresis should be considered as a temporary therapeutic bridge until conventional therapies can be instituted effectively or emergent surgery performed.

CONCLUSION

Although a rare scenario, the management of patients with severe thyrotoxicosis in the absence of a functional gastrointestinal tract represents a challenging clinical situation. Endocrinologists and critical care physicians should be apprised of the available treatment modalities which must be instituted swiftly in order to avoid a catastrophic outcome.

Is salt, vitamin, or endocrinopathy causing this encephalopathy? A review of endocrine and metabolic causes of altered level of consciousness

Altered level of consciousness describes the reason for 3% of critical emergency department (ED) visits. Approximately 85% will be found to have a metabolic or systemic cause. Early laboratory studies such as a bedside glucose test, serum electrolytes, or a urine dipstick test often direct the ED provider toward endocrine or metabolic causes. This article examines common endocrine and metabolic causes of altered mentation in the ED via sections dedicated to endocrine-, electrolyte-, metabolic acidosis-, and metabolism-related causes.

How to manage perioperative endocrine insufficiency

Patients with endocrinopathies frequently present to the operating room. Although many of these disorders are managed on a chronic basis, patients may have acute changes in the perioperative period that, if left unrecognized, can have a negative effect on perioperative morbidity and mortality. It is imperative that anesthesiologists understand the implications of the surgical stress response on hormonal flux. This article focuses on the 4 most commonly encountered endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Specific challenges pertaining to patients with pheochromocytoma are also discussed.

Thyroid storm presenting as intra-abdominal sepsis with multi-organ failure requiring intensive care

Thyroid storm is a rare but life-threatening condition manifesting with several clinical presentations. Atypical thyroid storm should be part of the differential diagnosis in patients with multiple organ dysfunction of unknown aetiology. In this case report, delayed recognition of thyroid storm in a young female who presented with acute abdomen increased the risk of poor outcome. Prompt initiation of anti-thyroid therapy once the diagnosis of thyroid storm was established, combined with adequate vital organ support using a goal-directed therapy protocol in the intensive care unit resulted in a good outcome.

Molar pregnancy-induced thyroid storm

BACKGROUND

Molar pregnancy is a rare form of pregnancy, affecting approximately 1 in 1000 pregnancies in the United States. Hyperthyroidism is a rare complication of molar pregnancy; thyroid storm occurs even less frequently.

OBJECTIVES

To discuss a rare cause of thyroid storm in a woman of reproductive age.

CASE REPORT

A 17-year-old girl presented to a community hospital's Emergency Department (ED) after experiencing 1 week of palpitations and tachycardia. The tachycardia partially responded to administration of calcium channel blockers and beta-blockers. The patient was transferred to a tertiary care center for further evaluation. At the tertiary center, pregnancy was confirmed, thyroid storm was diagnosed, and ultrasound examination yielded a snowstorm image, indicating a molar pregnancy. The patient was admitted to the intensive care unit for management. Dilatation and curettage resolved her symptoms, and after a 9-day hospital stay, she was discharged home on atenolol therapy.

CONCLUSIONS

Thyroid storm induced by gestational trophoblastic disease should be considered in any woman of childbearing age who presents with symptoms suggestive of hyperthyroidism.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Thyrotoxicosis and thyroid storm

Thyroid storm represents the extreme manifestation of thyrotoxicosis as a true endocrine emergency. Although Grave's disease is the most common underlying disorder in thyroid storm, there is usually a precipitating event or condition that transform the patient into life-threatening thyrotoxicosis. Treatment of thyroid storm involves decreasing new hormone synthesis, inhibiting the release of thyroid hormone, and blocking the peripheral effects of thyroid hormone. This multidrug, therapeutic approach uses thionamides, iodine, beta-adrenergic receptor antagonists, corticosteroids in certain circumstances, and supportive therapy. Certain conditions may warrant the use of alternative therapy with cholestyramine, lithium carbonate, or potassium perchlorate. After the critical illness of thyroid storm subsides, definitive treatment of the underlying thyrotoxicosis can be planned.

Pilot Study Using SELDI-TOF−MS Based Proteomic Profile for the Identification of Diagnostic Biomarkers of Thyroid Proliferative Diseases

Biomarkers for thyroid cancer (TCa) lack specificity. To develop TCa specific biomarkers, SELDI-TOF-MS was used to examine the proteomic profile of biopsies obtained from papillary TCa along with adjacent normal tissue. Sixty-three potential biomarkers were categorized by univariate analysis into single biomarker candidates and segregated by multivariate analysis into normal and cancerous groups. Our studies demonstrate the sensitivity and reproducibility of this approach to detect biomarkers for TCa.