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Abstract
Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturbances, and hyperthermia. Management of subclinical hyperthyroidism and thyrotoxicosis without thyroid storm is heavily dependent on outpatient evaluation. Thyroid storm is the most severe form of hyperthyroidism with the highest mortality. Management of thyroid storm follows a stepwise approach, with resuscitation and detection of the precipitating cause being paramount. Special attention should be paid to cardiac function in patients with thyroid storm before treatment, as these patients may develop cardiac collapse.
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Affiliation(s)
- Brannon L Inman
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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2
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Eltahir M, Chaudhry H, Ibrahim EA, Mokhtar M, Jaouni H, Hassan IF, El-Menyar A, Shehatta AL. Thyroid Storm-Induced Refractory Multiorgan Failure Managed by Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case-Series. Am J Case Rep 2023; 24:e940672. [PMID: 37614021 PMCID: PMC10461322 DOI: 10.12659/ajcr.940672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/17/2023] [Accepted: 06/22/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Severe hyperthyroidism, including thyroid storm, can be precipitated by acute events, such as surgery, trauma, infection, medications, parturition, and noncompliance or stoppage of antithyroid drugs. Thyroid storm is one of the serious endocrinal emergencies that prompts early diagnosis and treatment. Early occurrence of multiorgan failure is an ominous sign that requires aggressive treatment, including the initiation of extracorporeal membrane oxygenation (ECMO) support as a bridge to stability and definitive surgical treatment. Most adverse events occur after failure of medical therapy. CASE REPORT We described 4 cases of fulminating thyroid storm that were complicated with multiple organ failure and cardiac arrest. The patients, 3 female and 1 male, were between 39 and 46 years old. All patients underwent ECMO support, with planned thyroidectomy. Three survived to discharge and 1 died after prolonged cardiac arrest and sepsis. All patients underwent peripheral, percutaneous, intensivist-led cannulation for VA-ECMO with no complications. CONCLUSIONS Early recognition of thyroid storm, identification of the cause, and proper treatment and support in the intensive care unit is essential. Patients with thyroid storm and cardiovascular collapse, who failed to improve with conventional supportive measures, had the worst prognosis, and ECMO support should be considered as a bridge until the effective therapy takes effect. Our case series showed that, in patients with life-threatening thyroid storm, VA-ECMO can be used as bridge to stabilization, definitive surgical intervention, and postoperative endocrine management. Interprofessional team management is essential, and early implantation of VA-ECMO is likely beneficial in patients with thyroid storm after failure of conventional management.
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Affiliation(s)
- Mugahid Eltahir
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hamza Chaudhry
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ezzeddin Abdulsalam Ibrahim
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Marwa Mokhtar
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hani Jaouni
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
- Department of Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Labib Shehatta
- Department of Internal Medicine, Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medicine, Doha, Qatar
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Park SJ, Kim DJ, Hong YS, Lim SH, Park J. Acute right ventricular failure evoked by trauma induced thyroid storm supported by extracorporeal membrane oxygenation: A case report. Medicine (Baltimore) 2022; 101:e29359. [PMID: 35960049 PMCID: PMC9371557 DOI: 10.1097/md.0000000000029359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Cardiac arrest due to thyroid storm is a very rare clinical feature with high mortality that presents as multiorgan dysfunction. The mortality rate under this condition is close to 30%, even with appropriate treatment. Most thyroid storms occur in patients with long-standing untreated hyperthyroidism. PATIENT CONCERNS A 67-year-old woman, who had no specific medical history, was admitted with stupor mentality after a pedestrian traffic accident. DIAGNOSIS The patient had a Burch and Wartofsky score of 80, well beyond the criteria for diagnosis of a thyroid storm (>45 points). INTERVENTIONS Venoarterial extracorporeal membrane oxygenation (ECMO) was performed due to persistent unstable vital signs and findings of right ventricular dysfunction after return of spontaneous circulation after cardiopulmonary resuscitation. Circulatory assist with ECMO was performed for 8 days using a beta blocker, steroids, thionamide, and Lugol iodine solution. OUTCOMES Myocardial function and thyroid hormone levels were rapidly normalized. The patient's mental state recovered, and patient was discharged on day 36 maintaining medication. LESSONS Diagnosis of a thyroid storm in patients with multiple trauma is very difficult, because most trauma patients have symptoms of tachycardia, altered mental status, and abdominal pain that appear in thyrotoxic events. However, when unexplained shock without bleeding evidence occurs in patients with multiple trauma, a thyroid function test should be performed to rule out thyroid storm. Moreover, if hyperthyroidism is observed in a trauma patient, even if there is no history of hyperthyroidism, the possibility of a thyroid storm must be considered along with medical support treatment such as ECMO in patient with cardiogenic shock.
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Affiliation(s)
- Soo Jin Park
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Do Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - You Sun Hong
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang Hyun Lim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jiye Park
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- *Correspondence: Jiye Park, MD, Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164, Worldcup-ro, Yeongtong-gu, Suwon, 16499, Korea (e-mail: )
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4
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de Mul N, Immink RV. How to survive the thyroid storm: what we can learn from case reports. Br J Anaesth 2022; 129:e76-e77. [PMID: 35871022 DOI: 10.1016/j.bja.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Nikki de Mul
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Rogier V Immink
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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5
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De Almeida R, McCalmon S, Cabandugama PK. Clinical Review and Update on the Management of Thyroid Storm. Mo Med 2022; 119:366-371. [PMID: 36118802 PMCID: PMC9462913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves' disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis. The purpose of this article is a clinical review of the various treatments and methodologies to achieve a euthyroid state in patients with thyroid storm prior to definitive therapy.
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Affiliation(s)
- Reuben De Almeida
- Internal Medicine Resident, University of Missouri-Kansas City-School of Medicine (UMKC-SOM), Kansas City, Missouri
| | - Sean McCalmon
- Endocrinology Fellow at UMKC-SOM, Kansas City, Missouri
| | - Peminda K Cabandugama
- Assistant Professor of Medicine and Faculty Member of the Endocrinology Fellowship Program at the UMKC-SOM, Kansas City, Missouri
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Nasrullah A, Azharuddin S, Young M, Kejas A, Dumont T. Endocrine Emergencies in the Medical Intensive Care Unit. Crit Care Nurs Q 2022; 45:266-284. [PMID: 35617093 DOI: 10.1097/cnq.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endocrine emergencies are underdiagnosed and often overlooked amid the management of severe multisystem pathologies in critically ill patients in the medical intensive care unit (ICU). In an appropriate clinical scenario, a low threshold of suspicion should be kept to investigate for various life-threatening, yet completely treatable, endocrinopathies. Prompt identification and treatment of endocrine emergencies such as diabetic ketoacidosis, myxedema coma, thyroid storm, and/or adrenal insufficiency leads to fewer complications, shorter ICU and hospital stay, and improved survival. This review article entails common endocrine emergencies encountered in the ICU and addresses their epidemiology, pathophysiology, clinical presentation and management.
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Affiliation(s)
- Adeel Nasrullah
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, Pennsylvania (Drs Nasrullah, Azharuddin, Young, and Dumont); and Department of Nursing, Allegheny Health Network, Pittsburgh, Pennsylvania (Ms Kejas)
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7
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Tsang DA, Tan YH. Acute hypercapnic respiratory failure in thyroid storm and the role of plasma exchange. Ann Acad Med Singap 2022; 51:186-188. [PMID: 35373243 DOI: 10.47102/annals-acadmedsg.2021423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Denise Ann Tsang
- Department of Internal Medicine, Singapore General Hospital, Singapore
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8
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Keyai NK, Nepal N, Khanal S. Thyroid storm presenting as septic shock in the intensive care unit: A Case Series. JNMA J Nepal Med Assoc 2020. [PMID: 32335640 PMCID: PMC7580483 DOI: 10.31729/jnma.4552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Thyroid storm is a rare endocrine emergency that rarely presents with septic shock. It occurs in thyrotoxic patients and is manifested by decompensation of multiple organs, triggered by severe stress. The diagnosis and response to treatment is made by Burch-Wartofsky point scale or Japanese thyroid association criteria due to lack of pathophysiology of thyroid storm. We reported series of patients that presented with altered sensorium, cough, fever, palpitation, shortness of breath and shock. Patient were treated initially for septic shock, later diagnosed as thyroid storm and was treated with oral carbimazole, propanolol and digoxin. From this, we want to emphasize that thyroid storm can have any presentation that should be kept in differential diagnosis of septic shock not responding to usual treatment; early diagnosis and treatment with oral medication can decrease morbidity and mortality in rural setting where intravenous form of antithyroid drug are not available for thyroid storm.
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Affiliation(s)
- Niraj Kumar Keyai
- Department of Critical Care Medicine, B&C Medical College and Teaching Hospital, Birtamode, Nepal
- Correspondence: Dr. Niraj Kumar Keyal, Department of Critical Care Medicine, B&C Medical College and Teaching Hospital, Birtamode, Nepal. , Phone: +977-9855027141
| | - Niru Nepal
- Department of Anaesthesia & Critical Care, B&C Medical College Teaching Hospital, Birtamode, Nepal
| | - Sudesh Khanal
- Department of Critical Care Medicine, B&C Medical College and Teaching Hospital, Birtamode, Nepal
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9
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Affiliation(s)
- Ulla Feldt-Rasmussen
- 1Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Charles H Emerson
- 2Department of Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Douglas S Ross
- 3Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Peter A Kopp
- 4Division of Endocrinology, Diabetes and Metabolism, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Elizabeth N Pearce
- 5Boston University School of Medicine, Section of Endocrinology, Diabetes, and Nutrition, Boston, Massachusetts
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10
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Abstract
Thyroid emergencies are rare life-threatening endocrine conditions resulting from either decompensated thyrotoxicosis (thyroid storm) or severe thyroid hormone deficiency (myxedema coma). Both conditions develop out of a long-standing undiagnosed or untreated hyper- or hypothyroidism, respectively, precipitated by an acute stress-associated event, such as infection, trauma, or surgery. Cardinal features of thyroid storm are myasthenia, cardiovascular symptoms, in particular tachycardia, as well as hyperthermia and central nervous system dysfunction. The diagnosis is made based on clinical criteria only as thyroid hormone measurements do not differentiate between thyroid storm and uncomplicated hyperthyroidism. In addition to critical care measures therapy focusses on inhibition of thyroid hormone synthesis and secretion (antithyroid drugs, perchlorate, Lugol's solution, cholestyramine, thyroidectomy) as well as inhibition of thyroid hormone effects in the periphery (β-blocker, glucocorticoids).Cardinal symptoms of myxedema coma are hypothermia, decreased mental status, and hypoventilation with risk of pneumonia and hyponatremia. The diagnosis is also purely based on clinical criteria as measurements of thyroid hormone levels do not differ between uncomplicated severe hypothyroidism and myxedema coma. In addition to substitution of thyroid hormones and glucocorticoids, therapy focusses on critical care measures to treat hypoventilation and hypercapnia, correction of hyponatremia and hypothermia.Survival of both thyroid emergencies can only be optimized by early diagnosis based on clinical criteria and prompt initiation of multimodal therapy including supportive measures and treatment of the precipitating event.
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Affiliation(s)
- C Spitzweg
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.
| | - M Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - R Gärtner
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
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11
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Rastogi V, Singh D, Mazza JJ, Parajuli D, Yale SH. Flushing Disorders Associated with Gastrointestinal Symptoms: Part 2, Systemic Miscellaneous Conditions. Clin Med Res 2018; 16:29-36. [PMID: 29650526 PMCID: PMC6108508 DOI: 10.3121/cmr.2017.1379b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/30/2017] [Accepted: 12/21/2017] [Indexed: 12/12/2022]
Abstract
Flushing disorders with involvement of the gastrointestinal tract represent a heterogeneous group of conditions. In part 1 of this review series, neuroendocrine tumors (NET), mast cell activation disorders (MCAD), and hyperbasophilia were discussed. In this section we discuss the remaining flushing disorders which primarily or secondarily involve the gastrointestinal tract. This includes dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications. With the exception of paroxysmal pain disorders, panic disorders and some medications, these disorders presents with dry flushing. A detailed and comprehensive family, social, medical and surgical history, as well as recognizing the presence of other systemic symptoms are important in distinguishing the different disease that cause flushing with gastrointestinal symptoms.
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Affiliation(s)
- Vaibhav Rastogi
- University of Central Florida College of Medicine/HCA, Consortium Graduate Medical Education, North Florida, Regional Medical Center, 6500 W Newberry Rd, Gainesville, FL 32605
- University of Central Florida College of Medicine, 6850, Lake Nona Blvd, Orlando, FL 32827
| | - Devina Singh
- Feinstein Institute for Medical Research, 350 Community, Dr. Manhasset, NY 11030
| | - Joseph J Mazza
- Marshfield Clinic Research Institute, 1000 North Oak, Avenue, Marshfield, WI 54449
| | - Dipendra Parajuli
- University of Louisville, Department of Medicine, Gastroenterology, Hepatology and Nutrition. Director, Fellowship Training Program, Director, Medical Procedure Unit Louisville VAMC 401 East Chestnut Street, Louisville, KY 40202
| | - Steven H Yale
- University of Central Florida College of Medicine/HCA, Consortium Graduate Medical Education, North Florida, Regional Medical Center, 6500 W Newberry Rd, Gainesville, FL 32605.
- University of Central Florida College of Medicine, 6850, Lake Nona Blvd, Orlando, FL 32827
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12
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Davis S, McIntyre R, Cribari C, Dunn J. Thyroid Storm Induced by Trauma: A Challenging Combination. Am Surg 2018; 84:e44-e46. [PMID: 30454474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Stephanie Davis
- Division of GI, Tumor, and Endocrine Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
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13
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Pangtey GS, Baruah U, Baruah MP, Bhagat S. Thyroid Emergencies: New Insight into Old Problems. J Assoc Physicians India 2017; 65:68-76. [PMID: 28799309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thyroid emergencies are major life-threatening endocrine conditions associated with life-threatening disorders resulting from either severe deficiency or excess of thyroid hormones. Deficiency of thyroid hormones may present as myxedema coma whereas excessive hormone production can present as life threatening thyrotoxic storm. The diagnosis of both requires a high index of clinical suspicion. Thyroid storm, in spite of accurate diagnosis, continues to have high fatality, whereas myxedema management has markedly improved with advancement in intensive care facility. The key to successful management of these emergencies is timely diagnosis and management by experienced physician in an intensive care setting. This article discusses the basic differences of both entities with an attempt to appropriate recognition and awareness of clinical signs and symptoms, highlight the salient diagnostic points and delineate the rational approach, which can lead to appropriate treatment at the earliest and reduce mortality.
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Affiliation(s)
| | - Udismita Baruah
- Senior Resident, Dept. of Anesthesia, VMMC & Safdurjung Hospital, New Delhi
| | - Manash P Baruah
- Senior Consultant, Excel Center (Excel Care Hospitals), Guwahati, Assam
| | - Sahil Bhagat
- Senior Resident, Dept. of Medicine, LHMC and Associated Hospitals, New Delhi
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14
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McGonigle AM, Tobian AAR, Zink JL, King KE. Perfect storm: Therapeutic plasma exchange for a patient with thyroid storm. J Clin Apher 2017; 33:113-116. [PMID: 28608527 DOI: 10.1002/jca.21560] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/01/2017] [Accepted: 05/22/2017] [Indexed: 11/07/2022]
Abstract
Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8-2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8-1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.
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Affiliation(s)
- Andrea M McGonigle
- Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Hemapheresis and Transfusion Support (HATS), Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Aaron A R Tobian
- Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Hemapheresis and Transfusion Support (HATS), Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jennifer L Zink
- Hemapheresis and Transfusion Support (HATS), Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Karen E King
- Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Hemapheresis and Transfusion Support (HATS), Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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15
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Baena JC, Padilla J, Guzmán G. [Thyroid storm associated with multiorganic dysfunction]. Medicina (B Aires) 2017; 77:337-340. [PMID: 28825582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
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.
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Affiliation(s)
- Juan Camilo Baena
- Servicio de Medicina Interna, Fundación Valle del Lili, Cali, Colombia
| | - Jacobo Padilla
- Servicio de Medicina Interna, Fundación Valle del Lili, Cali, Colombia
| | - Guillermo Guzmán
- Servicio de Endocrinología, Fundación Valle del Lili, Cali, Colombia. E-mail:
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Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, Kanamoto N, Otani H, Furukawa Y, Teramukai S, Akamizu T. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J 2016; 63:1025-1064. [PMID: 27746415 DOI: 10.1507/endocrj.ej16-0336] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Tetsurou Satoh
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
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17
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Abstract
Hyperthyroidism is characterised by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The most common cause of hyperthyroidism is Graves' disease, followed by toxic nodular goitre. Other important causes of thyrotoxicosis include thyroiditis, iodine-induced and drug-induced thyroid dysfunction, and factitious ingestion of excess thyroid hormones. Treatment options for Graves' disease include antithyroid drugs, radioactive iodine therapy, and surgery, whereas antithyroid drugs are not generally used long term in toxic nodular goitre, because of the high relapse rate of thyrotoxicosis after discontinuation. β blockers are used in symptomatic thyrotoxicosis, and might be the only treatment needed for thyrotoxicosis not caused by excessive production and release of the thyroid hormones. Thyroid storm and hyperthyroidism in pregnancy and during the post-partum period are special circumstances that need careful assessment and treatment.
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Affiliation(s)
- Simone De Leo
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Sun Y Lee
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Lewis E Braverman
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
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Akamizu T. [Endocrine and Metabolic Emergencies; Points of Initial Management. Topics: III. Thyroid storm]. Nihon Naika Gakkai Zasshi 2016; 105:653-657. [PMID: 27491258 DOI: 10.2169/naika.105.653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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19
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Ku BD, Park KC, Yoon SS. Fatal ischemic stroke in a case of progressive moyamoya vasculopathy associated with uncontrolled thyrotoxicosis. Korean J Intern Med 2015; 30:543-6. [PMID: 26161023 PMCID: PMC4497344 DOI: 10.3904/kjim.2015.30.4.543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 09/22/2008] [Accepted: 11/10/2008] [Indexed: 11/27/2022] Open
Affiliation(s)
- Bon D. Ku
- Department of Neurology, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Key-Chung Park
- Department of Neurology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sung Sang Yoon
- Department of Neurology, Kyung Hee University School of Medicine, Seoul, Korea
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20
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Abstract
Neonatal thyroid storm is rare; the diagnostic criteria and management of neonatal thyroid storm have not been well established. In this paper, we report a preterm infant diagnosed with neonatal hyperthyroidism secondary to maternal Graves' disease who was discharged after therapy. Unfortunately, he was rehospitalised for neonatal thyroid storm. We will discuss the diagnosis and general therapy of neonatal thyroid storm.
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Huang J, Lu Q, Yu JL. [Thyroid storm in a newborn infant]. Zhongguo Dang Dai Er Ke Za Zhi 2014; 16:659-660. [PMID: 24927448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Jing Huang
- Department of Neonatology, Affiliated Hospital, Chongqing Medical University, Chongqing 400014, China
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22
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Shimoda Y, Satoh T, Takahashi H, Katano-Toki A, Ozawa A, Tomaru T, Horiguchi N, Kaira K, Nishioka M, Shibusawa N, Hashimoto K, Wakino S, Mori M, Yamada M. A case of thyroid storm with a markedly elevated level of circulating soluble interleukin-2 receptor complicated by multiple organ failure and disseminated intravascular coagulation syndrome. Endocr J 2014; 61:691-6. [PMID: 24748455 DOI: 10.1507/endocrj.ej14-0073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Thyroid storm (TS) is a life-threatening endocrine emergency. However, the pathogenesis of TS is poorly understood. A 40-year-old man was admitted to a nearby hospital with body weight loss and jaundice. Five days after a contrasted abdominal computerized tomography (CT) scan, he exhibited high fever and disturbance of consciousness. He was diagnosed with TS originating from untreated Graves' disease and was transferred to the intensive care unit (ICU) of our hospital. The patient exhibited impaired consciousness (E4V1M4 in Glasgow coma scale), high fever (39.3°C), and atrial flutter with a pulse rate 162/min, and was complicated by heart failure, acute hepatic failure, and disseminated intravascular coagulation syndrome (DIC). His circulating level of soluble interleukin-2 receptor (sIL-2R), a serum marker of an activated immune response, was highly elevated (7,416 U/mL, reference range: 135-483). Multiple organ failure (MOF) and DIC were successfully managed by multimodality treatments using inorganized iodide, glucocorticoids, anti-thyroid drugs, beta-blockers, and diuretics as well as an anticoagulant agent and the transfusion of platelet concentrate and fresh frozen plasma. sIL-2R levels gradually decreased during the initial treatment, but were still above the reference range even after thyroidectomy. Mild elevations in serum levels of sIL-2R have previously been correlated with thyroid hormone levels in non-storm Graves' disease. The present study demonstrated, for the first time, that circulating sIL-2R levels could be markedly elevated in TS. The marked increase in sIL-2R levels was speculated to represent an inappropriate generalized immune response that plays an unknown role in the pathogenesis of TS.
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Affiliation(s)
- Yoko Shimoda
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
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23
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Jha S, Waghdhare S, Reddi R, Bhattacharya P. Thyroid storm due to inappropriate administration of a compounded thyroid hormone preparation successfully treated with plasmapheresis. Thyroid 2012; 22:1283-6. [PMID: 23067331 DOI: 10.1089/thy.2011.0353] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Thyroid storm (TS) is a rare life-threatening condition that is characterized by fever and altered mental status precipitated by endogenous or exogenous critical events, illness/injury, acute iodine load, and thyroid or non thyroid surgery. A large number of thyroid extracts are available and extensively used, even though they are not recommended clinically in hypothyroid or euthyroid patients. Consumption of such products can be dangerous and result in life-threatening TS. Here, we report a case of TS caused by inadvertent intake of very high dosages of triiodothyronine (T3) and thyroxine (T4) in compounded thyroid extracts. Plasmapheresis may be considered an option for the management of exogenous TS. PATIENT FINDINGS A 62-year-old woman with no significant past medical history presented with severe myalgia, fever, tachycardia, and blood pressure of 170/80 mmHg, which precipitated to an altered mental state within 24 hours. Neurological examination did not reveal any focal deficit or any signs of meningeal irritation. Further investigation revealed that she had been taking thyroid supplements. The patient had accidentally been supplied with a batch of thyroid extract pills that had an inadvertently high content of T4. Her free T3 (FT3) and free T4 (FT4) levels were found to be very high beyond the laboratory readable range (FT3>30 pg/mL; FT4>6.06 ng/dL; thyrotropin [TSH]=0.07 IU/mL). SUMMARY Three days post commencement of standard conservative management of TS, the patient developed posterior reversible encephalopathy syndrome, resulting in a seizure. She remained unresponsive and in a poor mental state. The confirmed exogenous etiology for TS led to a decision to conduct plasmapheresis. Plasmapheresis conducted for two consecutive days proved successful as a therapeutic measure for TS and improved her thyroid profile as well as her mental state. CONCLUSIONS The inappropriate use of thyroid extracts in euthyroid and hypothyroid patients can result in life-threatening TS. Plasmapheresis is probably a life-saving treatment in patients who are exposed to amounts of thyroid hormone far in excess of that usually produced by the thyroid gland.
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Affiliation(s)
- Sujeet Jha
- Department of Endocrinology, Max Health Care, Max Healthcare Institute Ltd., New Delhi, India.
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24
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Abstract
We report a case of young woman who presented with acute cardiogenic pulmonary oedema and respiratory failure. She underwent emergent endotracheal intubation and was transferred to the intensive care unit. She responded to intravenous diuretics and positive pressure ventilation. Subsequent workup revealed that she had Graves' disease and was in thyrotoxic crisis. Therapy with propranolol and propylthiouracil was instituted to which she showed remarkable improvement.
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Affiliation(s)
- Atul Vijay Palkar
- Department of Internal Medicine, St Vincent Hospital, Worcester, Massachusetts, USA
| | | | - Nivedita D Moulick
- Department of Internal Medicine, Lokmanya Tilak Municipal Medical College & Hospital, Mumbai, India
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25
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Abstract
This review presents current knowledge about the thyroid emergencies known as myxedema coma and thyrotoxic storm. Understanding the pathogenesis of these conditions, appropriate recognition of the clinical signs and symptoms, and their prompt and accurate diagnosis and treatment are crucial in optimizing survival.
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Affiliation(s)
- Joanna Klubo-Gwiezdzinska
- Division of Endocrinology, Department of Medicine, Washington Hospital Center, Washington, DC 20010-2910, USA
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26
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Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011; 21:593-646. [PMID: 21510801 DOI: 10.1089/thy.2010.0417] [Citation(s) in RCA: 501] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition. METHODS The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis. CONCLUSIONS One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Rebecca S Bahn Chair
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic , Rochester, Minnesota 55905, USA.
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Abstract
We describe a 48-year-old man with thyroid storm presenting with heart failure. He presented severely impaired left ventricular wall motion and a marked increase in the liver enzymes. He developed disseminated intravascular coagulation on day 2. Due to elevated serum thyroid hormone level, anti-thyroid hormone receptor antibody positivity, and his clinical symptoms, he was diagnosed as thyroid storm due to untreated Graves' disease. His condition did not improve even after 6 days of conventional therapy including steroids. After therapeutic plasma exchange was carried out, his thyroid hormone level decreased markedly. Consequently, his condition recovered gradually, and he was discharged at day 43.
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Affiliation(s)
- Kazuki Sasaki
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Japan
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29
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Shah SN. Thyroid emergencies. J Assoc Physicians India 2011; 59 Suppl:66. [PMID: 21819006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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30
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Yoshino T, Kawano D, Azuhata T, Kuwana T, Kogawa R, Sakurai A, Tanjoh K, Yanagawa T. A patient with Graves' disease who survived despite developing thyroid storm and lactic acidosis. Ups J Med Sci 2010; 115:282-6. [PMID: 20731531 PMCID: PMC2971487 DOI: 10.3109/03009734.2010.486908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 56-year-old woman with Graves' disease presented with the complaints of diarrhea and palpitations. Physical examination and laboratory data revealed hypothermia and signs of mild hyperthyroidism, heart failure, hepatic dysfunction with jaundice, hypoglycemia, and lactic acidosis. The patient was diagnosed as having developed the complication of thyroid storm in the absence of marked elevation of the thyroid hormone levels, because of the potential hepatic and cardiac dysfunctions caused by heavy alcohol drinking. A year later, after successful treatment, the patient remains well without any clinical evidence of heart failure or hepatic dysfunction. Thyroid storm associated with lactic acidosis and hypothermia is a serious condition and has rarely been reported. Prompt treatment is essential even if the serum thyroid hormone levels are not markedly elevated. We present a report about this patient, as her life could eventually be saved.
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Affiliation(s)
- Tetsuhiro Yoshino
- Department of Internal Medicine, Nerima General Hospital, Asahigaoka, Nerima-ku, Tokyo,Japan
| | - Daisuke Kawano
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Oyaguchi Kamimachi, Itabashi-ku, Tokyo,Japan
| | - Takeo Azuhata
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Oyaguchi Kamimachi, Itabashi-ku, Tokyo,Japan
| | - Tsukasa Kuwana
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Oyaguchi Kamimachi, Itabashi-ku, Tokyo,Japan
| | - Rikimaru Kogawa
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Oyaguchi Kamimachi, Itabashi-ku, Tokyo,Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Oyaguchi Kamimachi, Itabashi-ku, Tokyo,Japan
| | - Katsuhisa Tanjoh
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Oyaguchi Kamimachi, Itabashi-ku, Tokyo,Japan
| | - Tatsuo Yanagawa
- Department of Internal Medicine, Nerima General Hospital, Asahigaoka, Nerima-ku, Tokyo,Japan
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31
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Akamizu T. [Therapy-resistant thyroid diseases. 2. Thyrotoxic crises]. Nihon Naika Gakkai Zasshi 2010; 99:763-768. [PMID: 20578363 DOI: 10.2169/naika.99.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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32
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33
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Kokott P. [Thyrotoxic crisis]. MMW Fortschr Med 2009; 151:40. [PMID: 19827444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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34
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Odagiri E. [Endocrine disorders (adrenal crisis and thyrotoxic crisis)]. Rinsho Byori 2009; Suppl 143:122-127. [PMID: 20845882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Emi Odagiri
- Central Clinical Laboratories, Tokyo Women's Medical University
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35
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Yuan YD, Seak CJ, Lin CC, Lin LJ. Thyroid storm precipitated by organophosphate intoxication. Am J Emerg Med 2007; 25:861.e1-3. [PMID: 17870509 DOI: 10.1016/j.ajem.2007.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 02/03/2007] [Indexed: 11/27/2022] Open
Affiliation(s)
- Yao-Dong Yuan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan, ROC
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36
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Mistovich JJ, Krost WS, Limmer DD. Beyond the basics: endocrine emergencies. Part 1: Hyperthyroidism and thyroid storm. EMS Mag 2007; 36:123-129. [PMID: 17983105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Abstract
INTRODUCTION Thyroid crisis is an acute manifestation of thyrotoxicosis. Approximately 1-2% of patients progress to a thyroid storm, often precipitated by a physiologically stressful event. If unrecognized or left untreated, thyroid storm may result in cardiovascular collapse and death. AIM We describe three patients who presented to the Emergency Department of Singapore General Hospital in a thyroid storm. They had complications of thyrocardiac disease with heart failure and arrhythmias. METHODS An analysis of case records of patients presenting to the emergency department of Singapore General Hospital with a primary diagnosis of thyrotoxicosis was made over the period of 2004-2005. Three patients with thyroid storm were identified. All the patients presented heart failure and cardiac arrhythmias (1 atrial flutter, 2 atrial fibrillation). DISCUSSION AND CONCLUSION Thyroid storm is a rare manifestation of thyrotoxicosis, usually occurring in females during the third to sixth decades of life. Serious complications such as heart failure and hypotension resulting in cardiovascular collapse and death may occur. Our case series consists of young males presenting with thyrocardiac failure. One patient was treated with beta-blockers and another with calcium channel blockers. Both developed cardiovascular collapse. The third patient was managed with digoxin with a good outcome. The current pathophysiology and therapeutic options are explored. A high index of suspicion should be maintained in young males presenting with heart failure and arrhythmia.
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Affiliation(s)
- Su Yin Adeline Ngo
- Singapore General Hospital, Department of Emergency Medicine, 3rd Hospital Avenue, Outram Raod, Singapore
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38
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Morrison MP, Schroeder A. Intraoperative identification and management of thyroid storm in children. Otolaryngol Head Neck Surg 2007; 136:132-3. [PMID: 17210350 DOI: 10.1016/j.otohns.2006.06.1248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 06/14/2006] [Indexed: 11/18/2022]
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Manouras A, Toutouzas KG, Markogiannakis H, Lagoudianakis E, Papadima A, Antonakis PT, Kafiri G, Bramis I. Intracystic hemorrhage in a mediastinal cystic adenoma causing parathyrotoxic crisis. Head Neck 2007; 30:127-31. [PMID: 17615565 DOI: 10.1002/hed.20661] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We report a case of intracystic hemorrhage in a mediastinal cystic parathyroid adenoma causing parathyrotoxic crisis. METHODS AND RESULTS A 30-year-old man presented with a large neck mass, dyspnea, and abdominal pain. The patient's serum calcium and parathormone levels were elevated. Radiography showed a right tracheal deviation, ultrasonography identified a thyroid nodular goiter extending to the mediastinum with a large (4.0 cm x 5.6 cm) cystic mass adjacent to the lower left thyroid pole. After IV fluid, pamidronate, and furosemide were administered, the patient underwent total thyroidectomy, and excision of the cyst and a small mass (2 cm x 2 cm) adjacent to the upper right thyroid lobe. Histopathologic examination revealed a double parathyroid adenoma and identified the mediastinal lesion as a cystic adenoma with intracystic hemorrhage. CONCLUSIONS Intracystic hemorrhage in a functional mediastinal cystic parathyroid adenoma is an extremely rare cause of parathyrotoxic crisis. Aggressive medical treatment should be immediately instituted, and surgery should be performed as soon as hypercalcemia is controlled.
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Affiliation(s)
- Andreas Manouras
- Department of Endocrine Surgery, First Department of Propaedeutic Surgery, Hippokration Hospital, University of Athens, Athens Medical School, Athens, Greece
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40
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Abstract
Thyroid storm is a rare but potentially fatal condition that is most frequently associated with Graves' disease. We present the case of a young woman who presented in thyroid storm, later diagnosed as being due to severe subacute thyroiditis. We discuss the diagnostic approach to thyroid storm, the initial management, and eventual treatment and course of subacute thyroiditis. This case illustrates the necessity to include subacute thyroiditis in the differential diagnosis of severe thyrotoxicosis and thyroid storm.
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Affiliation(s)
- Joanna L Swinburne
- Division of Endocrinology, St. Paul,s Hospital, University of British Columbia,Vancouver, British Columbia, Canada
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41
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Affiliation(s)
- Kim A Noble
- Temple University, CHP Jones Hall #415, 3307 N Broad St, Philadelphia, PA 19140, USA.
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42
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Fukata S. [Thyroid storm]. Nihon Rinsho 2006; Suppl 1:243-6. [PMID: 16776136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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43
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Reilly Lukela J, Mangrulkar RS, Tierney LM, DelValle J, Saint S. A midlife crisis. J Hosp Med 2006; 1:200-4. [PMID: 17219494 DOI: 10.1002/jhm.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jennifer Reilly Lukela
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48108, USA.
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44
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Abstract
The study of endocrine emergencies in childhood is important due to their high mortality and residual morbidity, that can be reduced with an adequate diagnosis and/or therapy. In this article, we review hypoglycemia, adrenal crisis, hypocalcemia, hypercalcemia and thyroid storm in children, with focus on initial diagnostic approach and management.
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Affiliation(s)
- Consuelo Aránguiz G
- Unidad de Endocrinología, Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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45
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Migneco A, Ojetti V, Testa A, De Lorenzo A, Gentiloni Silveri N. Management of thyrotoxic crisis. Eur Rev Med Pharmacol Sci 2005; 9:69-74. [PMID: 15850146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The thyrotoxic crisis is a medical emergency caused by an exacerbation of the hyperthyroid state characterized by decompensation of one or more organ systems. Early recognition and aggressive treatment are fundamental in limiting the morbidity and mortality associated with this condition. The crisis has an abrupt onset, and is evoked by a precipitating factor such as infectious diseases, ketoacidosis, acute trauma, thyroidal surgery, 131-I radio-metabolic treatment, administration of iodine-containing materials (amiodarone), parturition. The clinical picture is characterized by four main features: fever, tachycardia or supraventricular arrhythmias, central nervous system symptoms and finally gastrointestinal symptoms. The diagnosis of thyrotoxic crises is often made on the basis of clinical findings alone, since it is difficult in most emergency departments to obtain rapid confirmatory laboratory or nuclear medicine tests. The ultrasound thyroid scan, if available in the emergency room, may suggest an hyperthyroid state showing typical images of Basedow's disease or nodular goiter with their characteristic color-Doppler pattern of hyperactivity, easily distinguishable from a normal gland. The principles of thyroid storm treatments are: reduction of circulating TH's levels; inhibition of the peripheral effects of circulating thyroid hormones (TH); supportive care, in order to reverse systemic decompensation and treatment of the underlying precipitating event.
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Affiliation(s)
- A Migneco
- Department of Emergency Medicine, Catholic University - Rome (Italy)
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46
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Al-Anazi KA, Inam S, Jeha MT, Judzewitch R. Thyrotoxic crisis induced by cytotoxic chemotherapy. Support Care Cancer 2004; 13:196-8. [PMID: 15459765 DOI: 10.1007/s00520-004-0713-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Accepted: 09/07/2004] [Indexed: 11/25/2022]
Abstract
Thyroid storm is a rare and life-threatening medical emergency. We report a young lady with Graves' disease and acute myeloid leukaemia who developed thyrotoxic crisis following an induction course of chemotherapy given for the treatment of acute leukaemia. After successful management of her leukaemia and thyroid disease, she received an autologous bone marrow transplantation.
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Affiliation(s)
- Khalid A Al-Anazi
- Section of Adult Haematology and Bone Marrow Transplant, Department of Oncology, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, 11211, Riyadh, Saudi Arabia.
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47
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Hung W, Sarlis NJ. Autoimmune and non-autoimmune hyperthyroidism in pediatric patients: a review and personal commentary on management. Pediatr Endocrinol Rev 2004; 2:21-38. [PMID: 16429101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Here we review the etiology, diagnosis, differential diagnosis, and clinical presentation of hyperthyroidism in neonates/infants, children, and adolescents and the standard and adjunct modalities used for its treatment. The most common cause of hyperthyroidism in pediatric patients is Graves' disease. The main options for its management include antithyroid drugs, surgery, and radioiodine therapy. Despite collective experience covering more than 4 decades in the management of hyperthyroidism in children, controversy still abounds regarding the choice of treatments. None of the current treatment options is ideal. Each has risks and selection should be tailored to individual patients, especially in view of the absence of large, prospective, randomized outcome studies. Finally, we discuss the diagnosis and management of less common causes of pediatric hyperthyroidism, including non-autoimmune causes in neonates, autonomously functioning thyroid adenomas, destructive thyroiditis, excessive or inappropriate thyroid-stimulating hormone production, excessive ingestion of thyroid hormone and exposure to large, stable iodine loads.
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Affiliation(s)
- Wellington Hung
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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48
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Abstract
We report a 54-year-old female patient in whom thyroid storm was improved dramatically by plasma exchange. The patient presented with tachycardia, high fever and pulmonary congestion, in addition to left hemiparalysis and dysarthria. Serum thyroid hormone concentrations were markedly increased and computed tomography showed a fresh cerebral infarct, suggesting that she had thyroid storm precipitated by cerebral infarction. As there was no remarkable improvement even after 24 h of conventional therapy, plasma exchange was carried out using fresh frozen plasma. Consequently, her critical condition improved quickly. The half-life of thyroid hormones is so long that quick improvement is not always achieved even by sufficient doses of antithyroid drugs. Thus, plasma exchange in combination with conventional therapy appears to be effective in relieving the life-threatening state in our patient with thyroid storm precipitated by acute cerebral infarction.
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Affiliation(s)
- Toshiharu Kokuho
- Second Department of Internal Medicine, Yokohama City University School of Medicine, Yokohama, Japan.
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49
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Abstract
Thyrotoxicosis is a life-threatening disorder when encountered after a major surgical procedure. Plasma exchange is an occasionally reported alternative treatment to thyroidectomy, iodine ablative therapy, or the administration of thyreostatic drugs. We used plasmapheresis as a lifesaving treatment in a patient with thyrotoxicosis, as encountered after a left-sleeve pneumonectomy, in whom many classic therapies either failed or were not retained.
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Affiliation(s)
- Jurgen Petry
- Department of Intensive Care Medicine, University Hospital of Antwerp, Antwerp, Belgium
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50
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Abstract
Thyroid storm most often occurs in patients with known thyrotoxicosis. This report discusses a severe case of thyroid storm developing as a direct result of strangulation in a patient without a preexisting history of thyroid disease. Classification and treatment of this entity are discussed.
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Affiliation(s)
- Jesús I Ramírez
- Division of Trauma and Critical Care, Department of Surgery, Keck School of Medicine, University of Southern California, LAC+USC Medical Center, Los Angeles, CA 90033, USA
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