Intramuscular levothyroxine: a solution to a mental health related thyroid crisis.

A 53-year-old woman was admitted with thyroid storm and severe behavioural problems. She had longstanding bipolar affective disorder. She was psychotic and obstructed in-patient medical management for thyroid storm. She required one-to-one psychiatric nursing and was placed under section 3 of the Mental Health Act meaning she could be detained in hospital for psychiatric treatment for up to 6 months. She underwent a total thyroidectomy. Due to her paranoid mental state, she refused treatment and the administration of thyroid hormone replacement was difficult. Postoperatively, intramuscular levothyroxine was used effectively to stabilise her thyroid function. There are no consensus guidelines on the use of parenteral levothyroxine and intramuscular levothyroxine is rarely used. This case uniquely illustrates its utility with bi-weekly blood tests showing a fast and stable response to intramuscular hormone replacement.

[Thyroid Storm Precipitated by Intracranial Surgery in a Woman with No History of Thyroid Disease.]

Severe medical stress can trigger thyroid storm, an endocrine emergency that affects consciousness. This case report describes a 43-year-old female patient transferred to our hospital with right motor hemipare- sis. Her medical history included untreated hyperten- sion, but no history of thyroid disease. Emergency magnetic resonance imaging (MRI)of the head revealed bilateral moyamoya disease and ischemic stroke in the right watershed region of the brain. The right superfi- cial temporal artery was anastomosed to the middle cerebral artery on day 71 of hospitalization due to repeated brain infarctions after admission. Although anesthesia was without incident, the patient gradually developed postoperative disturbed consciousness, hypertension and tachycardia, which we considered were the result of craniotomy or insufficient brain per- fusion, until a nurse found a swelling on the patient's neck. Hyperthyroidism was confirmed by laboratory data and an endocrinologist concluded that thyroid storm had caused her symptoms. Thyroid storm should be considered in the differential diagnosis of patients who present with disturbed consciousness after intracranial surgery.

Thyroidectomy in a patient with thyroid storm: report of a case.

Thyroid storm is a life-threatening condition that is generally considered to be a contradiction to surgical intervention. We herein describe the case of a 37-year-old patient with a history of Graves' disease who was transferred to Tottori University Hospital with thyroid storm. She had been followed by her family doctor since 2006, but she had stopped taking her medication of her own volition in 2010. About ten days prior to her admission at our hospital, she consulted her family doctor with complaints of dyspnea, palpitations and general fatigue. Subsequent thyroid function tests showed TSH < 0.01 µU/ml, FT3 25.0 pg/ml and FT4 8.0 ng/dl. She also had acute heart failure, atrial fibrillation and hepatic failure. A diagnosis of thyroid storm was made and she was transferred to our hospital. She received steroids, beta blockade, potassium iodide, and plasma exchange, but her hepatic failure did not resolve and her clinical condition deteriorated. The decision was made to proceed with thyroidectomy. Postoperatively, her hepatic function normalized. Thus, thyroidectomy is a potential therapeutic choice for cases of thyroid storm refractory to medical management.

Jod-Basedow effect due to prolonged use of lugol solution-case report.

Graves' disease is the most common form of hyperthyroidism, accounting for 60-80% of all cases of thyrotoxicosis. If left untreated, it may lead to severe thyrotoxicosis with cardiovascular, ocular, psychiatric complication, and in extreme cases thyrotoxic crisis with a high mortality rate. We present the case of a 50-years-old woman diagnosed in another service with Graves' disease and treated for many years with antithyroid drugs (ATDs), admitted to our service for a relapse due to treatment discontinuation. The surgical treatment was planned and the preoperative preparation with Lugol solution was initiated. Due to a misunderstanding, the administration of iodine solution was extended for a period of about 30 days, thus generating the so-called Jod-Basedow effect, with the exacerbation of the manifestations of thyrotoxicosis and risk of thyroid storm. The patient received treatment with high ATDs doses, glucocorticoids, and beta-blockers, resulting in the progressive improvement of symptoms. She was discharged from hospital and given the risk of thyrotoxic crisis the surgery was postponed. After a month, the patient underwent thyroidectomy without preoperative preparation with iodine solution. The operative and postoperative courses were uneventful.

Thyroid storm complicated by fulminant hepatic failure: case report and literature review.

OBJECTIVES: Thyroid storm is a presentation of severe thyrotoxicosis that has a mortality rate of up to 20% to 30%. Fulminant hepatic failure (FHF) entails encephalopathy with severe coagulopathy in the setting of liver disease. It carries a high mortality rate, with an approximately 60% rate of overall survival for patients who undergo orthotopic liver transplantation (OLT). Fulminant hepatic failure is a rare but serious complication of thyroid storm. There have been only 6 previously reported cases of FHF with thyroid storm. METHODS: We present a patient from our institution with thyroid storm and FHF. A literature review was performed to analyze the outcomes of the 6 additional cases of concomitant thyroid storm and FHF. RESULTS: Our patient underwent thyroidectomy followed by OLT. Her serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, and transaminase normalized, and she was ready for discharge within 10 days of surgery. She has survived without complication. There is a 40% mortality rate for the reported patients treated medically with these conditions. Of the 7 total cases of reported FHF and thyroid storm, 2 patients died. Only 2 of the 7 patients underwent thyroidectomy and OLT--both at our institution. Both patients survived without complications. CONCLUSIONS: Thyroid storm and FHF each independently carry high mortality rates, and managing patients with both conditions simultaneously is an extraordinary challenge. These cases should compel clinicians to investigate liver function in hyperthyroid patients and to be wary of its rapid decline in patients who present in thyroid storm with symptoms of liver dysfunction. Patients with rapidly progressing thyroid storm and FHF should be considered for total thyroidectomy and OLT.

Thyroid storm in a patient with fulminant hepatic failure.

This manuscript describes a 28-year-old patient with a history of Graves' disease who was transferred to Tulane University Hospital with fulminant hepatic failure. He reported associated nausea, vomiting, anorexia, as well as jaundice and abdominal discomfort for a period of 3 weeks prior to his admission. His thyroid function tests on admission were TSH, 0.013 µU/mL; T3, 94.9 µU/mL; T4, 9.37 µU/mL; Free T4, >6 µU/mL. His liver function tests were characteristic of hepatic failure. The patient underwent an emergent liver transplant. His surgery was complicated by heart failure and acute respiratory distress syndrome. Given the patients clinical presentation and laboratory results, a diagnosis of thyroid storm was made and a decision was made to proceed with an emergent thyroidectomy. The posttransplant multiorgan dysfunction was rapidly reversed by prompt thyroidectomy and decisive management. The patient was discharged from the hospital with normal thyroid and liver function tests.

Successful treatment of thyroid storm with plasmapheresis in a patient with methimazole-induced agranulocytosis.

OBJECTIVE: To report a case of a patient with Graves disease presenting with agranulocytosis induced by methimazole, with subsequent thyroid storm and successful therapeutic use of plasmapheresis. METHODS: The clinical features and laboratory findings in a patient with agranulocytosis and thyroid storm are presented, and the available literature on utilization of plasmapheresis in the setting of thyrotoxicosis is reviewed. RESULTS: A 40-year-old Vietnamese woman with Graves disease was admitted with methimazole-induced agranulocytosis. Treatment with methimazole was discontinued, and therapy with antibiotics, granulocyte colony-stimulating factor, and ibuprofen was initiated. During hospitalization of the patient, her clinical status deteriorated, with development of pericarditis, thrombocytopenia, and thyroid storm. Treatment with plasmapheresis yielded near-euthyroidism in 3 days. Subsequently, she underwent successful total thyroidectomy. CONCLUSION: Our case highlights the effectiveness of plasmapheresis when clinical situations prohibit the use of traditional treatment methods for thyrotoxicosis or thyroid storm (or both).

[Diagnostic and therapeutic problems in thyrotoxic crisis in pregnant women. Influence of treatment on life and health of fetus and infant]. / Trudnosci diagnostyczne i terapeutyczne hipermetabolicznego przelomu tarczycowego u kobiet w ciazy. Wplyw leczenia na zycie i zdrowie plodu oraz noworodka.

Thyrotoxic crisis during pregnancy is a rare condition, but because of the danger it poses for the mother and fetus, every physician should be able to diagnose and treat it. When not recognized or incorrect treated hyperthyroidism, which is not easy to diagnose during pregnancy, is usually the basis for thyrotoxic storm. Serious conditions such as Graves' disease or multinodular goiter have to be distinguished from transient hyperthyroidism. Symptoms, such as: heat intolerance, hyperexia, emesis, tachycardia, increased pulse pressure and emotional liability should be considered cautiously because they are characteristic both for hyperthyroidism and for pregnancy. Interpretation of laboratory results need to take physiological changes during pregnancy into account--during the first trimester a low TSH serum concentration should be expected, whereas in the third trimester the free thyroxine (fT4) concentration decreases. Some conditions characteristic for pregnancy may be causative for thyrotoxic crisis: preeclampsia, placenta previa, labour induction, labour and cessarian section. Usually a hypermetabolic state has a characteristic, severe course but the possibility of monosystemic presentation must be kept in mind, because it is difficult to diagnose. Management of thyrotoxic crisis includes specific (thyrostatic agents, iodine preparations, adrenolytics, plasmaferesis) and supportive treatment. Thyrostatic agents (thiamazole and propylthiouracyl) can cross the placental barrier and similarly to iodine preparations can interfere with the pituitary-thyroid axis of the fetus. Additionally, thiamazole may cause specific embryopathy and should be considered as a second-line treatment. Adrenolytics affect the placental and uterine functions, and in high doses causes newborn hypoglycemia and bradycardia. A surgical approach is linked to an increased rate of preterm labour and miscarriage, but long-term effects are good.

[Experience of surgical treatment of diffuse thyrotoxic goiter in children and teenagers]. / Dosvid khirurhichnoho likuvannia dyfuznoho tyreotoksychnoho zobu u ditei ta pidlitkiv.

Results of surgical treatment of 137 children, operated on for thyrotoxic goiter (TG) in 1989-2002 yrs were analyzed. Thyrotoxic ophthalmopathy was revealed in 86 (62.7%) patients, papillary carcinoma on background of diffuse TG--in 3 (2.1%). Subtotal resection of thyroid gland according to O. V. Nikolayev was performed in 99 (72.2%) patients, almost thyroidectomy--in 30 (21.8%), thyroidectomy--in 8 (5.8%). All the patients are alive. Bilateral affection of nervus laryngeus recurrens was not observed. Unilateral injury of nervus laryngeus recurrens was revealed in 5 (3.6%) childs. Transient hypoparathyrosis was noted in 20 (14.5%) patients. The TG recurrence had occurred in 5 (3.6%) childs, postoperative hypothyrosis--in 100 (72.9%).

[Thyrotoxic crisis in a patient with Graves' disease]. / Thyreotoxische storm bij een patiënt met de ziekte van Graves.

A 33-year-old man presented with diarrhoea, dyspnoea, palpitations, fever and shock. One year and a half before admission, Graves'-hyperthyroidism had been diagnosed, for which he was treated with thiamazole and levothyroxine as block-replacement therapy. A diagnosis of thyrotoxic crisis, precipitated by lack of compliance with antithyroid drug therapy and possibly an underlying infection, was made. Euthyroidism was achieved with propylthiouracil, potassium iodide, corticosteroids and propranolol. However, the propylthiouracil had to be stopped due to agranulocytosis, after which hyperthyroidism recurred. An emergency thyroidectomy was then performed; the patient recovered completely. Thyrotoxic crisis is a rare, potentially life-threatening disease in patients with underlying un(der)treated hyperthyroidism. It is characterised by fever, tachycardia, and neurological and gastrointestinal symptoms.

Is there a place for thyroidectomy in older patients with thyrotoxic storm and cardiorespiratory failure?

Early thyroidectomy is the treatment of choice for thyrotoxic storm in patients with thyroid autonomy often induced by iodine. However, older patients who are mostly affected by this condition often have underlying chronic cardiopulmonary diseases, apparently contradicting surgical intervention. The published evidence for suitable treatment strategies in these patients is limited. We report the outcome of a series of older critically ill patients who were treated by thyroidectomy because of thyrotoxic storm. We retrospectively analyzed the outcome of 10 patients (4 males, 6 females; 70 years of age, range, 54-79, Burch-Wartofsky point scale, 61; range, 40-85) with thyrotoxic storm, thyroid autonomy, and severe cardiorespiratory and renal failure with cardiac arrhythmia, coronary artery or chronic obstructive pulmonary disease, or acute inflammation. Thyroidectomy was performed for the following reasons: symptoms of thyrotoxic storm deteriorated or did not improve within 24-48 hours despite intensive medical treatment, or patients developed thionamide-induced agranulocytosis or severe thrombocytopenia. All patients with severe accompanying diseases survived thyroidectomy (early post-operative mortality, 0%). The two oldest patients died 2-3 weeks after thyroidectomy because of myocardial infarction or respiratory failure (late postoperative mortality, 20%). In contrast, in the few previous reports of patients who underwent thyroidectomy for thyrotoxic storm and severe accompanying diseases (n = 7), late postoperative mortality was 43%. The overall mortality for all reported patients including our own, who underwent thyroidectomy for thyrotoxic storm with and without severe accompanying disease (n = 49) was 10%. Our results suggest that early total thyroidectomy should be considered as the method of choice for older, chronically ill patients with thyrotoxic storm complicated by cardiorespiratory and renal failure, especially if high-dose thionamide treatment, iopanoic acid, glucocorticoids, and intensive care fail to improve the patient's conditions within 12-24 hours.

[Early operation as a treatment measure in thyrotoxic crisis]. / Frühoperation als Behandlungsmassnahme der thyreotoxischen Krise.

INTRODUCTION: Thyroid storm is a rare disease, occurring in less than 1% of all thyrotoxicoses. Diagnosis and therapy still have serious problems. METHODS: We review 14 patients who were operated on between 1992 and 1999 because of thyroid storm. RESULTS: All of the ten women and four men, aged 27 to 77 years, had an underlying thyroid disease. Autonomies were found in seven, Grave's disease in four, and a nodular goiter in three patients. The precipitating events were in five patients an antiarrhythmic therapy with amiodarone, on three occasions application of contrast medium, two times omission of antithyroid drugs and in one patient severe hyperglycemia with acidosis. In three patients no triggering factor was discovered. All patients were treated with high-dose antithyroid therapy. On admission, four patients were graded as stage-one thyroid crisis, three patients had stage-two and seven patients stage-three disease. All patients were operated on within 18 h of admission. Surgical procedure was in seven cases a bilateral subtotal resection, four times thyroidectomy, and in three patients a Dunhill procedure. After the operation, 12 patients improved rapidly. Two 77 and 74-year-old women died 1 or 2 days after the operation, respectively, one from heart failure and the other from multiple organ failure. Both had been diagnosed as thyrotoxic crisis stage three. CONCLUSION: Early operation should be adopted as a standard option in thyroid storm that cannot be controlled medically. Best results are achieved if the operation is done at stage one or two of the disease.

Thyroidectomy in iodine induced thyrotoxic storm.

Between January 1996 and September 1997 we treated 4 patients with iodine-induced thyrotoxic storm (2 females, 2 men; age 54-77 years). Iodine contamination was due to iodine-containing contrast media in 3 patients and iodine-containing disinfectant in 1 patient. Thyroid storm with tachycardia, hypertension, sweating, tremor, weight loss and coma occured 3-10 weeks after iodine contamination. These symptoms were accompanied by raised fT4- and fT3-values. All 4 patients were initially treated with antithyroid drugs for 7 days, whereas 2 patients with coronary artery disease, demonstrated by coronary angio-graphy, were treated with antithyroid drugs for 2 weeks. Because of unsuccessful antithyroid drug treatment, all 4 patients underwent subtotal thyroidectomy. There were no perioperative complications. We conclude that early thyroidectomy is the appropriate treatment for iodine-induced thyrotoxicosis even in patients with severe accompanying diseases.

Thyrotoxic crisis in Graves' disease: indication for immediate surgery.

Thyrotoxic crisis (thyroid storm) is a rare complication of hyperthyroidism. It can be observed not only in thyroid autonomy with latent hyperfunction after exposure to iodine, but also in Graves' disease with overt hyperfunction. Adequate management of thyrotoxic crisis is still controversial. We report about four patients (four women, mean age 75 years) with Graves' disease who developed thyrotoxic crisis during therapy with antithyroid drugs so that surgical intervention became necessary. The patients had been admitted to the hospital for nonspecific symptoms such as headache, cachexy, and psychosis. Thyroid hormone levels had reached twice the normal range prior to surgery. All patients showed severe neurological deficits leading to coma. In three cases euthyroidism was achieved within two days after surgery. The neurological symptoms disappeared after an average of four days. The postoperative course did not show severe complications and all patients recovered completely. Especially in the elderly a monosymptomatic or nonspecific course of thyroid storm with neurological symptoms may represent a severe and life-threatening situation. In these cases surgery can become necessary even if euthyroidism has not been achieved preoperatively.

[Subtotal thyroid gland resection as therapy for thyrotoxic crises]. / Subtotale Schilddrüsenresektion als Therapiekonzept bei thyreotoxischer Krise.

Thyrotoxic crises occurred in six patients (four women aged 51, 63, 72 and 76 years; two men aged 52 and 63 years). In four patients the crisis was triggered by a contrast medium containing iodine, and in one by amiodarone. The cause of the crisis in the 51-year-old woman remained uncertain. After a latent period of up to two months, T3 and T4 concentrations rose in all the patients, and abnormal findings such as tachycardia, increased blood pressure, dehydration, tremor, restlessness, hallucinations and coma ensued. Because of ineffective conservative treatment, five patients underwent subtotal thyroidectomy. In all five the symptoms and signs of hyperthyroidism were promptly relieved, and the postoperative course was uneventful. The 76-year-old woman was considered unfit for surgery because of her cardiac condition, and she died of left ventricular failure resistant to therapy.