Prospective Multicenter Registry-Based Study on Thyroid Storm: The Guidelines for the Management from Japan are Useful

CONTEXT

The mortality rate in thyroid storm (TS) has been reported to be higher than 10%.

OBJECTIVE

We aimed to evaluate the effectiveness of the 2016 guidelines for the management of TS proposed by the Japan Thyroid Association and Japan Endocrine Society.

DESIGN

Prospective registry-based study through a secure web platform.

SETTING

Prospective multicenter registry.

PATIENTS AND MEASUREMENTS

Patients with new-onset TS were registered in the Research Electronic Data Capture (REDCap). On day 30 after admission, clinical information and prognosis of each patient were added to the platform. On day 180, the prognosis was described.

RESULTS

This study included 110 patients with TS. The median of Acute Physiology and Chronic Health Evaluation (APACHE) II score was 13, higher than the score in the previous nationwide epidemiological study, 10 (p = 0.001). Nonetheless, the mortality rate at day 30 was 5.5%, approximately half compared with 10.7% in the previous nationwide survey. Lower body mass index, shock and lower left ventricular ejection fraction were positively associated with poor prognosis at day 30, while the lack of fever ≥ 38℃ was related to the outcome. The mortality rate in patients with an APACHE II score ≥12 for whom the guidelines were not followed was significantly higher than the rate in patients for whom the guidelines were followed (50% vs. 4.7%) (p = 0.01).

CONCLUSIONS

Prognosis seemed better than in the previous nationwide survey, even though disease severity was higher. The mortality rate was lower when the guidelines were followed. Thus, the guidelines are useful for managing TS.

Hashimoto Encephalopathy and Thyroid Storm by Diabetic Ketoacidosis and Acute Pancreatitis: A Case Report

Hashimoto encephalopathy (HE) is a rare condition related to autoimmune origin characterized by high titers of antithyroid antibodies. Steroids are effective for treatment of HE, suggesting the autoimmunity as an underlying mechanism. In addition, anti-NH2-terminal of α-enolase antibodies (anti-NAE antibodies) is useful for diagnosis of HE. This report describes a 69-year-old woman developing both HE and thyroid storm (TS), following diabetic ketoacidosis (DKA) and acute pancreatitis. She had a history of Basedow's disease and uncontrolled type 2 diabetes mellitus, and her serum hemoglobin A1c was 10%. She complained of nausea and visited our hospital. She was diagnosed with DKA and acute pancreatitis. After admission, she went into cardiopulmonary arrest and she was diagnosed with TS after resuscitation. In addition, blood test collected during acute phase of TS revealed positive for not only anti-thyroid peroxidase (TPO) antibodies, thyroid stimulating hormone receptor antibodies and thyroid stimulating antibodies, but also anti-NAE antibodies. She was treated with intravenous steroids, potassium iodide and thiamazole under respirator and recovered sufficiently to do daily activities of life. We should keep in mind that there might be cases of HE in cases of TS presenting with central nervous system symptoms.

Advancing Preoperative Strategies for Thyroidectomy in Graves' Disease: A Narrative Review

Graves' disease is an autoimmune disorder characterized by thyroid-stimulating antibodies that can potentially lead to thyrotoxicosis, goiter, skin disease, and eye disease. Available treatment options for Graves' disease include management with antithyroid drugs (ATDs), thyroid ablation with radioactive iodine (RAI), and surgical thyroid gland removal. For individuals unable to reach a normal thyroid hormone level, promptly considering a thyroidectomy is essential. Preoperative strategies to achieve a euthyroid state prevent thyroid storms and minimize postoperative complications and are therefore crucial. While variations in professional guidance exist, this review focuses on standard medical interventions as well as compares respective guidelines set forth by the American Thyroid Association, the European Thyroid Association, the American Association of Clinical Endocrinology, and the American Association of Endocrine Surgeons. There is consensus among these organizations underscoring the importance of rendering patients euthyroid prior to surgery and the use of ATDs. Most guidelines recommend screening for vitamin D deficiency as well as endorse thyroidectomy as the preferred treatment option for hyperthyroidism with skilled surgeons. Nevertheless, discrepancies do become apparent in aspects such as potassium iodide (SSKI) course duration and preoperative dexamethasone administration. By understanding these differing approaches, healthcare professionals can more effectively manage Graves' disease prior to surgery, resulting in improved patient outcomes and enhanced surgical success.

The risk of perioperative thyroid storm in hyperthyroid patients: a systematic review

BACKGROUND

Thyroid storm is a feared complication in patients with hyperthyroidism undergoing surgery. We assessed the risk of thyroid storm for different preoperative treatment options for patients with primary hyperthyroidism undergoing surgery.

METHODS

Pubmed, EMBASE, and The Cochrane Library were searched systematically for all studies reporting on adult hyperthyroid patients undergoing elective surgery under general anaesthesia. Selected studies were categorised based on preoperative treatment: no treatment, antithyroid medication (thionamides), iodine, β-blocking medication, or a combination thereof. Treatment effect, that is restoring euthyroidism, was extracted from the publications if available. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) or the Cochrane Risk of Bias tool for randomised studies.

RESULTS

The search yielded 7009 articles, of which 26 studies published between 1975 and 2020 were selected for critical appraisal. All studies had moderate to critical risk of bias, mainly attributable to risk of confounding, classification of intervention status, and definition of the outcome. All studies reported on thyroidectomy patients. We found no randomised studies comparing the risk of thyroid storm between treated and untreated patients. Cases of thyroid storm were reported in all treatment groups with incidences described ranging from 0% to 14%.

CONCLUSION

Evidence assessing the risk of perioperative thyroid storm is of insufficient quality. Given the seriousness of this complication and the impossibility of identifying patients at increased risk, preoperative treatment of these patients remains warranted.

Acute appendicitis complicated by concomitant thyroid storm

We report a case of thyroid storm with concomitant acute appendicitis. The patient had clinical findings concerning for an acute abdomen. However, this physical examination finding can occur in some individuals presenting with severe thyrotoxicosis or thyroid storm without an underlying surgical process. In this case, the patient received aggressive treatment perioperatively for her thyroid storm and required continued treatment for her thyroid state after appendectomy. Differentiating medical vs surgical causes for an acute abdomen while simultaneously recognizing the thyrotoxic state is imperative in such a scenario. Clinicians must proceed cautiously to optimize patients' thyroid status before any operative interventions to minimize risks of cardiovascular collapse or death.

Thyroid Storm in Head and Neck Emergency Patients

Background: Thyroid storm is a rare but life-threatening emergency that prompts urgent intervention to halt its potentially disastrous outcomes. There is not much literature available on thyroid storm in head neck trauma and non-thyroid/parathyroid head neck surgery. Due to rarity of thyroid storm in head and neck trauma/surgery patients, its diagnosis becomes challenging, is often misdiagnosed and causes delay in the diagnosis and management. Therefore, the aim of this work was to compile, analyze and present details to develop a consensus and augment available literature on thyroid storm in this group of patients. Materials and methods: A comprehensive literature search of the last 30 years was performed on PUBMED/MEDLINE, EMBASE, CINAHL and Science Citation Index for thyroid storm using MeSH words and statistical analyses were performed. Results: Seven articles describing seven cases of thyroid storm were reviewed. All patients required medical management and one patient (14.3%) required adjunctive surgical management. Burch and Wartofsky Diagnostic criteria for thyroid storm were used in diagnosis of 42% patients. Time of diagnosis varied from immediately upon presentation to formulating a retrospective diagnosis of having a full-blown thyroid storm at 4 days post presentation. It was misdiagnosed and unthought of initially in majority of these cases, (71.4%) were not diagnosed in the first day of hospital stay. Conclusion: Early recognition of thyroid storm in head and neck patients markedly reduce morbidity/mortality. Albeit unexpected, it should be ruled out in any symptomatic head and neck trauma or post-surgery patient.

National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004-2013

BACKGROUND

Current evidence on the incidence and outcomes of patients with thyroid storm in the United States is limited to single-center case series. This study determined the national incidence of thyrotoxicosis with and without thyroid storm and clinical outcomes among hospitalized patients during a 10-year period in the United States.

METHODS

Retrospective longitudinal analysis was conducted of clinical characteristics, mortality, hospital length of stay, and costs from 2004 to 2013. Adults (≥18 years of age) with a primary diagnosis of thyrotoxicosis with and without thyroid storm were included. To determine the incidence, outcomes, and cost of thyrotoxicosis with and without thyroid storm, the study used data from the National Inpatient Sample database, the largest public inpatient database, with a representative sample of all non-federal hospitals in the United States.

RESULTS

Among 121,384 discharges with thyrotoxicosis during the study period (M_age ± standard error = 48.7 ± 0.11 years; 51.9% Caucasian; 77.3% female), 19,723 (16.2%) were diagnosed with thyroid storm. During the past decade, the incidence of thyroid storm ranged between 0.57 and 0.76 cases/100,000 U.S. persons per year, and 4.8 and 5.6/100,000 hospitalized patients per year. Thyroid storm was associated with significantly higher hospital mortality (1.2-3.6% vs. 0.1-0.4%, p < 0.01) and longer length of stay (4.8-5.6 vs. 2.7-3.4 mean days, p < 0.001) compared to patients with thyrotoxicosis without storm. Inflation-adjusted hospitalization costs progressively increased in patients with thyroid storm from $9942 to $12,660 between 2004 and 2013 (p < 0.01).

CONCLUSIONS

One of every six discharges for thyrotoxicosis was diagnosed with thyroid storm. Thyroid storm is associated with a 12-fold higher mortality rate compared to thyrotoxicosis without storm. The incidence and mortality of thyroid storm has not substantially changed in the past decade. However, hospitalization costs have significantly increased.

Weathering the Crisis: A Case of Thyroid Crisis with Propranolol-Induced Circulatory Collapse Successfully Treated with Therapeutic Plasma Exchange

Thyroid crisis is a life-threatening form of thyrotoxicosis characterized by multi-system dysfunction. Therapeutic plasma exchange has been reported to be effective in removing excessive circulating thyroid hormones. We present a 46-year-old female with recently diagnosed Graves’ disease associated with thyrotoxic cardiomyopathy admitted for thyroid crisis complicated by propranolol-induced circulatory collapse, acute kidney injury and ischemic hepatitis. The tachyarrhythmia was refractory to conventional therapy. Initiation of TPE resulted in rapid clinical and biochemical stabilization.

Thyroid Storm: A Japanese Perspective

BACKGROUND

Thyroid storm (TS) is life threatening. In the mid-2000s, its incidence was poorly defined, peer-reviewed diagnostic criteria were not available, and management and treatment did not seem to be verified based upon evidence and latest advances in medicine.

METHODS

First, diagnostic criteria were developed based on 99 patients in the literature and seven patients in this study. Then, initial and follow-up surveys were conducted from 2004 through 2008, targeting all hospitals in Japan to obtain and verify information on patients who met diagnostic criteria for TS. Based on these data, the diagnostic criteria were revised, and management and treatment guidelines were created.

RESULTS

The incidence of TS in hospitalized patients in Japan was estimated to be 0.20 per 100,000 per year and 0.22% of all thyrotoxic patients. The mortality rate was 10.7%. Multiple organ failure was the most common cause of death, followed by congestive heart failure, respiratory failure, and arrhythmia. In the final diagnostic criteria for TS, the definition of jaundice as serum bilirubin concentration >3 mg/dL was added. Based upon nationwide surveys and the latest information, guidelines for the management and treatment for TS were extensively revised and algorithms were developed.

CONCLUSIONS

TS remains a life-threatening disorder, with >10% mortality in Japan. New peer-reviewed diagnostic criteria for TS are presented and its clinical features, prognosis, and incidence are clarified based on nationwide surveys. Furthermore, this information helped to establish detailed guidelines for the management and treatment of TS. A prospective prognostic study to validate the guidelines is eagerly anticipated.

[Thyroid storm associated with multiorganic dysfunction]

Thyroid storm is a rare and potentially fatal condition. Unusual presentations in patients with thyroid storm have been described but multiorganic dysfunction is uncommonly seen. We describe the case of a 36-year-old woman with unknown underlying Graves's disease who developed thyroid storm. The thyroid storm score of Burch and Wartofsky was 50/140. This was complicated by acute liver failure, acute kidney injury, lactic acidosis, heart failure, bi-cytopenia, coagulopathy and rhabdomyolysis. The severe multiorgan dysfunction was reversed by prompt institution of steroids, cyclophosphamide and plasma exchange before thyroidectomy. Main difficulty lies in recognizing its varied presentations and offering appropriate treatment when physician faces either failure or contraindications of conventional therapy.

Endocrinopathies: The current and changing perspectives in anesthesia practice

The gateways to advancements in medical fields have always been accessed through the coalition between various specialties. It is almost impossible for any specialty to make rapid strides of its own. However, the understanding of deeper perspectives of each specialty or super specialty is essential to take initiatives for the progress of the other specialty. Endocrinology and anesthesiology are two such examples which have made rapid progress in the last three decades. Somehow the interaction and relationship among these medical streams have been only scarcely studied. Diabetes and thyroid pathophysiologies have been the most researched endocrine disorders so far in anesthesia practice but even their management strategies have undergone significant metamorphosis over the last three decades. As such, anesthesia practice has been influenced vastly by these advancements in endocrinology. However, a comprehensive understanding of the relationship between these two partially related specialties is considered to be an essential cornerstone for further progress in anesthesia and surgical sciences. The current review is an attempt to imbibe the current and the changing perspectives so as to make the understanding of the relationship between these two medical streams a little simple and clearer.

Out of the blue! Thyroid crisis

A 45-year-old male patient with an irregularly irregular rhythm and fast ventricular rate was posted for an emergency laparotomy for hollow viscus perforation. His history was not suggestive of any systemic disorders. An echocardiography revealed left ventricular dysfunction with an ejection fraction of 47% without any valvular or chamber abnormality. Thyromegaly noticed during placement of central venous catheter was suspected to be the etiology for his cardiovascular status and was successfully managed. Thyroid crisis in an undiagnosed case of hyperthyroidism poses a diagnostic and therapeutic challenge. Timely and aggressive management is essential to correct the homeostatic decompensation characteristic of thyroid storm.

Case report: clues to the diagnosis of an unsuspected massive levothyroxine overdose

There is currently little literature pertaining to levothyroxine overdose apart from minor or accidental overdoses in the pediatric population. In particular, there is little information available on how to confidently differentiate levothyroxine overdose from endogenous causes of thyrotoxicosis when there is no history available at the time of assessment. We report a levothyroxine (15,800 mcg) and citalopram (2,460 mg) overdose in a 55-year-old woman presenting with seizure and tachycardia in which the diagnosis was not initially suspected. Clinical data, including a long history of treated hypothyroidism and lack of a goiter; and biochemical findings, such as an incompletely suppressed thyroid-stimulating hormone (TSH) level, despite a markedly elevated free thyroxine level (FT4), a normal sex hormone-binding globulin level at baseline, and an undetectable thyroglobulin, supported the diagnosis of thyrotoxicosis due to a massive exogenous thyroid hormone overdose. Treatment was given to decrease free triiodothyronine (FT3) conversion and increase thyroid hormone clearance with dexamethasone and cholestyramine. The patient made a full recovery. Levothyroxine overdose can result in subtle symptoms and signs clinically, even when in massive quantities. This can make diagnosis challenging. Biochemical features, such as the pattern of thyroid hormone elevation and thyroglobulin levels, help differentiate exogenous thyroid hormone overdose from endogenous causes of thyrotoxicosis.