Life-threatening thyrotoxicosis induced by amiodarone in patients with benign heart disease

Anaesthetic implications of a case of hyperthyroidism detected during the closure of an atrial septal defect

A woman in her mid-20s who was clinically euthyroid presented with an ostium secondum atrial septal defect for closure. Preoperatively, heart rate ranged from 80 to 110 beats per minute. On the day of surgery, heart rate was 120 beats per minute, which settled after induction. During ultrasound guided central line access, a thyroid swelling was noticed. 20-30 min after commencement of the surgery, heart rate increased up to 130 beats per minute. Since other causes of tachycardia was ruled out, an intraoperative blood sample for thyroid function test was sent. Esmolol was kept ready in case the swelling turned out to be hyperfunctioning thyroid nodule. Post bypass, the patient again developed tachycardia. The thyroid function test showed elevated T3, T4 and a mildly elevated TSH (Thyroid stimulating hormone) value, consistent with an extrathyroid source. The patient is on long-term follow-up under an endocrinologist. Postoperatively, she is again euthyroid and heart rates have settled to less than 100 beats per minute.

Combination therapy of ipilimumab and nivolumab induced thyroid storm in a patient with Hashimoto's disease and diabetes mellitus: a case report

BACKGROUND

Recently, immune checkpoint inhibitors have widely been used for the management of advanced melanoma. However, high-grade immune-related adverse events can occur, particularly with combination immunotherapy. We report a case of a patient with melanoma who developed thyroid storm following treatment with ipilimumab and nivolumab.

CASE PRESENTATION

An 85-year-old Japanese man with a history of malignant melanoma presented to our department with severe thyrotoxicosis and poor blood glucose control. He was already being treated for Hashimoto's disease and type 2 diabetes mellitus before the treatment for the melanoma. During admission, laboratory investigations revealed the following thyroid functions: thyroid-stimulating hormone below sensitivity, free triiodothyronine 31.7 pg/ml, and thyroglobulin 48,000 IU/ml. Thyroid-stimulating hormone receptor antibody was negative, and a ^99mTc-labeled thyroid scan revealed a markedly decreased uptake. He was treated with beta-blocker, orally administered potassium iodine, a relatively low dose of prednisolone, and insulin injection therapy to control his blood glucose, resulting in an improvement in thyroid function and his symptoms.

CONCLUSION

It might be important to be aware of the possibility of thyroid storm induced by immune checkpoint inhibitors.

Predictive features associated with thyrotoxic storm and management

Thyroid storm (TS) is an endocrine emergency characterized by rapid deterioration, associated with high mortality rate therefore rapid diagnosis and emergent treatment is mandatory. In the past, thyroid surgery was the most common cause of TS, but recent preoperative medication creates a euthyroid state before performing surgery. An active approach during perioperative period could determine an effective clinical treatment of this life-threating diseases. Recently, the Japan Thyroid Association and Japan Endocrine Society developed diagnostic criteria for TS focusing on premature and prompt diagnosis avoiding inopportune e useless drugs. This review analyses predictive features associated with thyrotoxic storm highlighting recent literature to optimize the patient quality of care.

2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

Thyroid storm is an endocrine emergency which is characterized by multiple organ failure due to severe thyrotoxicosis, often associated with triggering illnesses. Early suspicion, prompt diagnosis and intensive treatment will improve survival in thyroid storm patients. Because of its rarity and high mortality, prospective intervention studies for the treatment of thyroid storm are difficult to carry out. We, the Japan Thyroid Association and Japan Endocrine Society taskforce committee, previously developed new diagnostic criteria and conducted nationwide surveys for thyroid storm in Japan. Detailed analyses of clinical data from 356 patients revealed that the mortality in Japan was still high (∼11%) and that multiple organ failure and acute heart failure were common causes of death. In addition, multimodal treatment with antithyroid drugs, inorganic iodide, corticosteroids and beta-adrenergic antagonists has been suggested to improve mortality of these patients. Based on the evidence obtained by nationwide surveys and additional literature searches, we herein established clinical guidelines for the management of thyroid storm. The present guideline includes 15 recommendations for the treatment of thyrotoxicosis and organ failure in the central nervous system, cardiovascular system, and hepato-gastrointestinal tract, admission criteria for the intensive care unit, and prognostic evaluation. We also proposed preventive approaches to thyroid storm, roles of definitive therapy, and future prospective trial plans for the treatment of thyroid storm. We hope that this guideline will be useful for many physicians all over the world as well as in Japan in the management of thyroid storm and the improvement of its outcome.

Treatment of Graves' disease: the advantages of surgery

The authors and others believe that surgery (thyroidectomy) is underused in the treatment for patients with Graves' disease. It is the most rapid and consistent method of making the patient euthyroid; it avoids the possible long-term risks of radioactive iodine; and it provides tissue for histologic examination. Children, young women, pregnant women, and patients with coexistent thyroid nodules are ideal candidates for thyroidectomy. It also is the treatment of choice for patients with Graves' ophthalmopathy. Patients should be rendered euthyroid before thyroidectomy. Although the operation is technically more difficult than operating on patients with nontoxic goiter or thyroid neoplasms because of the vascularity of the thyroid gland, this difference is small, and the complication rates are low. The authors recommend the Hartley-Dunhill operation (total thyroidectomy on one side and subtotal thyroidectomy on the other side, leaving about 4 to 5 g of thyroid tissue) for most patients and total thyroidectomy for patients with Graves' ophthalmopathy. In patients with recurrent or persistent thyroid cancer who fail to respond to surgery and radioactive iodine ablation, immunosuppressive therapy should be considered.

Lithium treatment in amiodarone-induced thyrotoxicosis

PURPOSE

Amiodarone hydrochloride is an iodine-rich drug effective in the control of various tachyarrhythmias. It is known to cause refractory to thyrotoxicosis, which usually does not respond to regular antithyroid drugs. Lithium bicarbonate is a medication used to treat psychiatric disorders; it also influences thyroid production and release of hormones. We tried it in combination with propylthiouracil (PTU) for the treatment of amiodarone-induced thyrotoxicosis.

PATIENTS AND METHODS

Twenty-one patients were studied. The first group (n = 5) was treated by amiodarone withdrawal only. The second group (n = 7) received PTU (300 to 600 mg), and the third (n = 9) PTU (300 mg) and lithium (900 to 1350 mg) daily. Patient selection was not randomized. The PTU + lithium group had more severe symptoms and signs of thyrotoxicosis, as well as thyroxine levels at least 50% above the upper limit of normal. They also had been on a longer course of amiodarone treatment (34.3 +/- 11.9 months) than the PTU-only (11.4 +/- 7.5) and the no-treatment (7.8 +/- 4.2) groups.

RESULTS

While there was no difference between the first two groups in time until recovery (10.6 +/- 4.0 versus 11.6 +/- 0.5 weeks, respectively), the group receiving lithium normalized their thyroid function tests in only 4.3 +/- 0.5 weeks (P < 0.01 versus both other groups). T3 levels normalized even earlier-by 3 weeks of lithium treatment. No adverse effects of lithium were encountered, and the medication was stopped 4 to 6 weeks after achieving a normal clinical and biochemical state.

CONCLUSIONS

We conclude that lithium is a useful and safe medication for treatment of iodine-induced thyrotoxicosis caused by amiodarone. We would reserve this treatment for severe cases only. Further studies are needed to find out whether in patients with this troublesome complication lithium therapy could permit continuation of amiodarone treatment.

Thyroid storm

Despite earlier recognition and treatment of hyperthyroidism, thyroid storm remains a life-threatening, although fortunately rare, medical emergency. Prompt recognition and aggressive treatment employing a multifaceted approach are generally effective at correcting the homeostatic decompensation that is the hallmark of thyroid storm. Research is furthering understanding of the cellular actions of thyroid hormone and may lead to additional, even more effective treatment modalities in the future.

Amiodarone-induced thyrotoxicosis: is there a place for surgery?

Amiodarone-induced hyperthyroidism has on most instances been reported as mild, and thyroid functions return to normal after discontinuation of the drug. Nevertheless, life-threatening amiodarone-induced thyrotoxicosis has also been described. Conventional treatments such as antithyroid drugs (thionamide) and corticosteroids are essentially ineffective or fail to alter the dramatic course of the thyroid crisis. This limited effectiveness of medical therapy, particularly in patients with previously neglected or unknown thyroid disease, prompted us to intervene surgically. We report a series of nine patients who underwent total or near-total thyroidectomy as a first-line therapy for five of them. Surgery resulted in rapid resolution of thyrotoxicosis with an uneventful postoperative course. This approach has the advantage of immediate effectivity, low risk of relapse, and appears to be the only treatment that permits continued therapy with amiodarone when the drug appears needed to control a life-threatening arrhythmia.