Apathetic Thyroid Storm with Cardiorespiratory Failure, Pulmonary Embolism, and Coagulopathy in a Young Male with Graves' Disease and Myopathy

Elevated serum CD40 as a potential biomarker for the differential diagnosis of acute thyrotoxic myopathy

Acute thyrotoxic myopathy (ATM) is a rare yet severe complication of thyrotoxicosis that affects the central nervous system and is associated with a high mortality rate if not diagnosed and treated promptly. Currently, the diagnosis of ATM primarily relies on clinical manifestations, and there is a lack of specific serological markers to support the diagnostic process. This study aimed to investigate the differences in serum CD40 levels between patients with acute thyrotoxic myopathy (ATM), those with Graves' disease, and healthy controls, and to evaluate its potential as a diagnostic biomarker for differentiating ATM. Additionally, the study examined the correlation between serum CD40 levels and various parameters, including the ATM symptom score (ATMSS), FT3, FT4, TSH, TGAb, TRAb, and TPOAb. This retrospective cross-sectional study included 17 patients with ATM, 17 patients with Graves' disease, and 17 healthy controls, all recruited from the First Affiliated Hospital of Guangxi Medical University between January 2022 and August 2024. Clinical evaluations, serum thyroid hormone and related antibody testing, and CD40 level measurements were conducted. The predictive value of CD40, FT3, FT4, TSH, TGAb, TRAb, and ATMSS for ATM was assessed using receiver operating characteristic (ROC) curve analysis. Spearman correlation analysis was performed to explore the relationship between CD40 levels and ATMSS, FT3, FT4, TSH, TGAb, TRAb, and TPOAb. Serum levels of CD40[259.17(227.50,378.03)vs.190.71(174.08,198.96)vs. 166.98(142.94,175.90)], FT3[28.34(17.13,37.65) vs. 8.82(6.36,21.00) vs. 5.02(3.93,5.45)], and FT4 [67.58(37.53,77.23)vs.27.03(15.96,47.05)vs.16.82(13.59,17.90)]in ATM patients were significantly higher than those in Graves' disease patients and the control group, with statistically significant differences (P < 0.01). ROC analysis demonstrated that CD40 has high predictive value for distinguishing between GD and ATM, with an area under the curve (AUC) of 0.99, and both sensitivity and specificity of 94.1%. Correlation analysis revealed a positive correlation between CD40 and the ATM symptom score (ATMSS) (r = 0.72, P < 0.01). Positive correlations were also observed between CD40 and FT3 (r = 0.53, P < 0.01) and FT4 (r = 0.56, P < 0.01). TSH showed a negative correlation trend with CD40 (r = -0.21, P = 0.23), but this difference was not statistically significant. No significant correlations were found between CD40 and TGAb (r = 0.10, P = 0.59), TRAb (r = 0.26, P = 0.13), or TPOAb (r = 0.06, P = 0.72). Elevated serum CD40 levels are associated with the severity of ATM symptoms and may serve as a potential biomarker for ATM. The role of CD40 as an adjunct in the early diagnosis of ATM holds clinical significance, offering new insights into the differential diagnosis and treatment of ATM.

Comparing the Incidence of Propranolol and Esmolol-Related Cardiac Arrest in Patients With Thyroid Storm: A Systematic Literature Review

A precarious complication of thyrotoxicosis, or thyroid storm, is the increased risk of cardiomyopathy, which leads to circulatory collapse and cardiopulmonary arrest. It is crucial to promptly identify this condition to prevent significant deterioration of the left ventricular function and cardiogenic shock. This article seeks to examine published research that emphasizes the connection between thyroid storm and beta-blocker usage in relation to cardiogenic collapse and provides management recommendations. The search was performed on September 9, 2022, using PubMed, Science Direct, and Google Scholar libraries. A systematic exploration was carried out using the keywords Thyroid Storm AND cardiogenic Shock AND cardiac arrest AND beta blocker. The use of beta blockers as part of thyroid storm management was linked to the development of cardiogenic collapse and cardiac arrest. Ultra-short-acting beta-blockers like esmolol were a safer option than propranolol in treating patients with a thyrotoxic storm.

Fatal Case of Possible Thyroid Crisis Induced by SARS-CoV-2 Infection: A Case Report

Thyroid crisis is an emergency due to impaired thyroid function caused by various conditions, particularly infections such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that result in the dysfunction of various vital organs. We report a case of a 31-year-old Indonesian female with a 2-year history of hyperthyroidism with elevated thyroid-stimulating hormone (TSH) receptor antibodies. (TRAb) who developed thyroid crisis possibly in association with SARS-CoV-2 pneumonia, sepsis, and disseminated intravascular coagulation (DIC). Prior to admission, she was treated for her hyperthyroidism with propylthiouracil and had been in stable remission for a year. She was admitted to the Emergency Room with complaints of watery stools, icteric sclerae, jaundice, coughing, and shortness of breath. The physical examination showed a World Health Organization (WHO) performance score of 4, delirium, blood pressure within normal limits, tachycardia, tachypnea, axillary temperature of 36.7°C, icteric sclerae, jaundice, and exophthalmos. There was a 3 cm palpable nodule on the right side of the neck. Auscultation of the lungs revealed bilateral pulmonary rales. Abdominal examination noted a palpable liver and enlarged spleen. Laboratory tests showed thrombocytopenia, electrolyte imbalance, hypoalbuminemia and elevated transaminases. The thyroid function tests showed a suppressed TSH level with an elevated free thyroxine (FT4) level. The SARS-CoV-2 polymerase chain reaction (PCR) swab test was positive. Initial patient management was with supportive therapy that included favipiravir and anti-hyperthyroidism medication; however, despite these interventions, her condition continued to deteriorate and she died after a few hours. This case demonstrates no difference in therapy between patients with thyroid crises and COVID-19 or other infections. Proper and timely treatment is important for reducing mortality rates.

Thyroid Storm-Induced Acute Liver Dysfunction and Disseminated Intravascular Coagulation

Thyroid storm-induced disseminated intravascular coagulation (DIC) is a very rare complication of untreated/undertreated Graves' disease. It is considered to be a medical emergency as it can rapidly lead to hemodynamic instability in patients due to multi-organ failure. Although the exact pathogenesis of this hematological phenomenon remains poorly understood, it is believed to be triggered by the uncontrolled release of pro-inflammatory cytokines, which in turn prematurely activates the coagulation cascade. In this report, we present the case of a 48-year-old female who presented with symptoms of abdominal pain, dyspnea, and unintentional weight loss for the past several weeks. Her vital signs, overall clinical picture, and laboratory tests confirmed thyroid storm complicated by DIC and acute liver injury. The patient made a significant recovery after the initiation of methimazole therapy.