Cerebral venous sinus thrombosis caused by traumatic brain injury complicating thyroid storm: a case report and discussion.

INTRODUCTION: Cerebral venous sinus thrombosis (CVST) is an uncommon cerebrovascular disease with diverse predisposing factors. We report a case of CVST caused by a thyroid storm induced by traumatic brain injury. CASE PRESENTATION: A 29-year-old male patient with a history of Graves' disease with hyperthyroidism presented to our hospital with head trauma of cerebral contusion and laceration in both frontal lobes confirmed by admission CT scan. He received mannitol to lower intracranial pressure, haemostatic therapy, and antiepileptic treatment. Eight days later, he presented with signs of thyroid storms, such as tachycardia, hyperthermia, sweating and irritation, and his thyroid function tests revealed high levels of TPO-Ab, TR-Ab, TG-Ab, FT3 and FT4. Then, he entered a deep coma. His brain CT showed a thrombosis of multiple venous sinuses, along with the opening of peripheral collateral vessels, congestive infarction with haemorrhage and brain swelling. He regained consciousness after treatment with antithyroid drugs, anticoagulants, respiratory support and a regimen of sedation/analgesia. After a half-year follow-up, most of the patient's blocked cerebral venous sinuses had been recanalized, but there were still some sequelae, such as an impaired fine motor performance of the right hand and verbal expression defects. CONCLUSIONS: CVST can be induced by thyroid storms, and trauma-related thyroid storms can develop on the basis of hyperthyroidism. The purpose of this case report is to raise clinicians' awareness and improve their ability to diagnose CVST early in patients with traumatic brain injury complicating thyroid storms to improve the neurological prognosis among similar patients.

SARS-CoV-2 infection induced thyroid storm and heart failure in an adolescent girl.

We report a case of thyroid storm precipitated by SARS-CoV-2 infection in an adolescent girl with a history of Graves disease and dilated cardiomyopathy. This case highlights that SARS-CoV-2 infection can potentially trigger a thyrotoxicosis crisis and acute decompensated heart failure in a patient with underlying thyroid disease and myocardial dysfunction even in the absence of multi-system inflammatory syndrome in children. We systematically reviewed the thyrotoxicosis cases with SARS-CoV-2 infection and described its impact on pre-existing dilated cardiomyopathy.

Thyroid Storm Superimposed on Gestational Hypertension: A Case Report and Review of Literature.

A thyroid storm is an extreme manifestation of thyrotoxicosis, and is life threatening without an early diagnosis. Pregnancy or childbirth may worsen maternal hyperthyroidism or induce the development of a thyroid storm. Gestational hypertension, a disorder defined as new-onset hypertension, develops after 20 weeks of gestation and shares symptoms with a thyroid storm. The diagnosis of a thyroid storm may be challenging in patients with gestational hypertension. To highlight the significance of early thyrotoxicosis-related gastrointestinal symptoms, we report a case of a 38-year-old woman with a twin pregnancy, who was diagnosed with gestational hypertension, and then developed a thyroid storm during the peripartum period. She complained of nausea and abdominal pain, followed by tachycardia, hypertension, and a disturbance of consciousness with desaturation. After emergency caesarean section, fever, diarrhea, and high-output heart failure, with pulmonary edema, were noted during the postoperative period in the intensive care unit. The diagnosis of a thyroid storm was confirmed using the Burch-Wartofsky point scale, which was 75 points. In this patient, the uncommon gastrointestinal symptoms, as initial manifestations of thyrotoxicosis, indicated the development of a thyroid storm. The distinguished presentation of thyrotoxicosis-induced cardiomyopathy and peripartum cardiomyopathy also helped in the differential diagnosis between a thyroid storm and gestational hypertension. Aggressive treatment for thyrotoxicosis should not be delayed because of a missed diagnosis.

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, ß-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.

Low-dose oral propranolol for treatment of thyrotoxic periodic paralysis with hypokalaemia in the emergency department: A case report.

WHAT IS KNOWN AND OBJECTIVE: Thyrotoxic periodic paralysis (TPP) with hypokalaemia is a rare acute phenomenon. Reports of the use of high-dose non-selective ß-blockers describe symptom resolution, but often administration does not occur promptly enough in the treatment course and patients may experience overcorrection and hyperkalaemia. CASE DESCRIPTION: A 37-year-old Hispanic male developed TPP. Patient was successfully treated with low-dose oral propranolol and potassium supplementation with no overcorrection. WHAT IS NEW AND CONCLUSION: Delay in the administration of non-selective ß-blockers may lead to overcorrection of potassium with exogenous supplementation. Low-dose propranolol administered in the Emergency Department was successful in preventing overcorrection of potassium.

Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases.

BACKGROUND: Simultaneous development of thyroid storm and diabetic ketoacidosis (DKA) is a rare condition. The review aims to summarise its clinical presentation, investigation findings and treatment options. METHODS: Databases and reference lists of the selected articles were searched for case reports in English which describe concurrent presentation of thyroid storm and diabetic ketoacidosis. CARE guidelines were used for the quality assessment of the selected articles. RESULTS: Twenty-six cases from twenty-one articles were selected out of 198 search results. Western Pacific, and American regions contributed to 77% of the cases. Females were most affected (88%). Features of Graves' disease like hyperthermia and tachycardia, gastrointestinal and neuro-psychiatric disturbances were the common clinical presentations. In most of the cases, previous diagnosis of diabetes mellitus preceded that of Graves' disease (46%). Among patients having their drug compliance reported, all had poor compliance to their routine anti-thyroid (9/9) and anti-diabetic (2/2) agents. Moreover, in all cases where HbA1C (7/7) and T4 (16/16) were measured, the results were elevated and where TSH (17/17) was measured, the results were low. The recommended treatment for DKA and thyroid storm was used in most cases and methimazole was the thionamide of choice in the latest four cases reported. All cases survived except four (15%). CONCLUSIONS: Concurrent presentation of thyroid storm and diabetic ketoacidosis is rare but life-threatening. Therefore, efforts should be made to maximise patient compliance to anti-thyroid and anti-diabetic agents in treating such patients.

Diltiazem-Associated Cardiogenic Shock in Thyrotoxic Crisis.

CLINICAL FEATURES: The patient we present is a 39-year-old woman with a history of hyperthyroidism who developed fast atrial fibrillation secondary to thyrotoxic storm. After the initiation of intravenous diltiazem drip, she developed hypotension, bradycardia, then asystole cardiac arrest. THERAPEUTIC CHALLENGE: It is well known that calcium channel blockers and beta blockers should be used with extreme caution if the patient with thyroid storm has decompensated heart failure with reduced ejection fraction. Despite this, it is recognized that guidelines for the management of thyroid storm do not include an algorithm of action in this situation. Thus, dealing with low-output failure during thyroid storm may pose a critical challenge. SOLUTION: A significant portion of patients with thyrotoxic storm have an underlying low-output cardiac failure. Early identification, proper hemodynamic monitoring, and administration of the agents with appropriate pharmacodynamic profile and therapeutic potentials are essential to avoid treatment-induced cardiogenic shock.

Flushing Disorders Associated with Gastrointestinal Symptoms: Part 2, Systemic Miscellaneous Conditions.

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.

Thyroid storm and myxoedema: two reversible causes of acute heart failure.

Cardiovascular signs and symptoms can prevail in both hypothyroidism and hyperthyroidism. Case 1: 30-year-old female with acute right heart failure as first manifestation of Graves' disease. It illustrates some of its cardiovascular complications, particularly pulmonary hypertension, tricuspid regurgitation, atrial fibrillation, mitral valve prolapse and mitral regurgitation. Case 2: 83-year-old-man with a severe primary hypothyroidism/myxoedema crisis presented to emergency department with extreme bradyarrhythmia with hemodynamic impact and heart failure signs, which led to implantation of definitive pacemaker. Thyroid disorders are treatable entities and most cardiovascular changes are reversible. Early diagnosis is mandatory and can avoid severe complications and, eventually, invasive therapeutics interventions. Pulmonary hypertension and acute heart failure, especially in young adults, should be screened for underlying hyperthyroidism.

Iodinated Contrast Administration Resulting in Cardiogenic Shock in Patient with Uncontrolled Graves Disease.

BACKGROUND: Thyroid storm (also known as thyroid or thyrotoxic crisis) is part of the spectrum of thyrotoxicosis and represents the extreme end of that spectrum. The condition is quite rare, yet mortality rates are high and may approach 10-30%. CASE REPORT: A 34-year-old-man who had a history of Graves disease presented in atrial fibrillation with rapid ventricular response and mild congestive heart failure. During the course of his Emergency Department (ED) stay he deteriorated into cardiogenic shock. Roughly 10 h transpired between his presentation and the development of cardiogenic shock. He had received an intravenous contrast load of iohexol shortly after initial presentation, and the associated iodine bolus, we suspect, contributed to his abrupt deterioration into cardiogenic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Thyroid storm is infrequently seen in the ED, and there is potential for management errors that can lead to a detrimental patient outcome.

[Thyroid storm associated with multiorganic dysfunction]. / Tormenta tiroidea asociada a disfunción multiorgánica.

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.

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

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

Low cardiac output thyroid storm in a girl with Graves' disease.

A 15-year-old girl with Graves' disease presented with hypotension after methimazole and propranolol were re-started for hyperthyroidism. She was found to have pulmonary artery hypertension resulting in obstructive shock. Thyroid storm was diagnosed according to Burch and Wartofsky score. She was promptly treated with anti-thyroid drugs, inorganic iodide, corticosteroid, and respiratory support. Pulmonary hypertension was treated with inhaled nitric oxide until the clinical status improved. Propranolol was withdrawn due to poor cardiac function. We herein present a unique case of a difficult-to-treat Graves' disease presenting with severe pulmonary hypertension resulting in low cardiac output thyroid storm.

Jaundice Heralding the Onset of Thyrotoxic Crisis.

Thyrotoxic crisis is a life threatening medical condition that requires urgent diagnosis and treatment. Because of the wide variety of presenting symptoms, its diagnosis can be difficult in some cases and a high index of suspicion is required for diagnosis. We present a case of 53 year old patient who presented with fever, jaundice and passage of loose stools. Upon investigations other etiologies for hepatic injury were ruled out and she was found to be in thyrotoxic crisis causing liver injury.

[Successful Resuscitation Using Percutaneous Cardiopulmonary Support in a Woman with Acute Heart Failure during a Thyroid Storm].

Thyroid storm is a rare, life-threatening condition characterized by severe manifestations of thyrotoxico- sis. Acute heart failure is one of the well-known com- plications of thyrotoxicosis. Thyrotoxicosis-induced heart failure sometimes causes circulatory collapse with high mortality. A 43-year-old woman had palpitations and exertional dyspnea without medical history. She developed con- gestive heart failure, due to tachycardiac atrial fibrilla- tion with no acute ischemic changes. High serum level of FT3 and FT4, and low level of TSH were shown in thyroid function tests, and thyromegaly in carotid ultrasound test She was admitted to the intensive care unit for acute heart failure caused by thyroid storm. Two days after admission, cardiopulmonary resuscitation and endotracheal intubation were necessary due to sudden cardiac arrest Transthoracic echocardiogram showed normal cardiac function after successful resuscitation. Five days after admission, her condition deteriorated with severe cardiac dysfunction, and she received PCPS (percutaneous cardiopulmonary support) for cardiovascular collapse resulting in persistent tachy- cardiac atrial fibrillation. Ten days after initiation of PCPS, the patient's cardiovascular function improved with estimated left ventricular ejection fraction of 50 percent and she was weaned off PCPS. In the case of acute heart failure with untreated hyperthyroid and refractory atrial fibrillation, careful hemodynamic management is required to avoid cardio- vascular collapse.

[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.

Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis.

OBJECTIVE: The objectives of this study were (1) to describe the presentation, demographics, and clinical course of patients admitted for thyroid storm, and (2) to identify factors associated with mortality. METHODS: A retrospective review of subjects admitted to a single academic hospital from 2006 through 2011 was conducted. Medical records for all patients who were admitted with a diagnosis of thyrotoxicosis were systematically reviewed for clinical features of thyroid storm. RESULTS: A total of 28 cases were identified. Thyroid storm was the first clinical presentation of thyrotoxicosis in 13 patients (46.4%). Noncompliance with treatment was a major trigger in previously diagnosed patients, followed by infection. The mortality rate was 25% in this series. Cardiac manifestations were predominant, with >60% of patients having severe tachycardia (heart rate >140 beats per minunte) and/or atrial fibrillation. Although central nervous system (CNS) involvement was less frequent (n = 8, 28.6%), CNS derangement of worse than mild severity was statistically associated with mortality (P = .021). There was good agreement between the Burch-Wartofsky Point Scale and Japanese Thyroid Association criteria in the diagnosis of thyroid storm in this study cohort. CONCLUSION: Thyroid storm was the first presentation of thyrotoxicosis in a significant proportion of patients, highlighting the importance of a high index of suspicion in an appropriate clinical context. The presence of neuropsychiatric manifestations appeared to portend greater risk of mortality. Prevailing evidence suggests that there are complex interactions between thyroid hormones and neurotransmitter circuits in the pathogenesis of CNS symptomology in thyrotoxicosis.

Thyroid storm-induced multi-organ failure in the setting of gestational trophoblastic disease.

BACKGROUND: Thyroid storm is a potentially life-threatening complication of gestational trophoblastic disease (GTD), with varying clinical severity. It should be considered in patients with GTD, abnormal vital signs, and clinical signs of hyperthyroidism. CASE REPORT: A 45-year-old non-English-speaking patient presented to a New York City hospital in November 2011 with an aborting molar pregnancy and severe hemorrhage. Initial presentation was concerning for GTD. Laboratory values were obtained that confirmed the diagnosis of GTD, which was also by thyroid storm and congestive heart failure. This was evidenced by laboratory values of free thyroxine of 4.9 and beta human chorionic gonadotropin of 1,488,021 IU/mL. Dilation and curettage with 16-mm suction catheter was performed until all products of conception were removed and bleeding was controlled. The patient was admitted to the surgical intensive care unit and proceeded to have multi-organ failure, and remained intubated and unresponsive to verbal/visual and tactile stimuli. On postoperative day 13 the patient suddenly became alert and self-extubated, began to communicate verbally, and resolution of her multi-organ failure became evident. The patient was discharged with Gynecologic Oncology follow-up. Why should an emergency care physician be aware of this? This case represents the dangers associated with poor prenatal care and late diagnosis of molar pregnancy. It also represents the need for immediate recognition of the condition and initiation of appropriate medical care. Although this patient's clinical outcome was good, the event could have been prevented had she received reliable medical care.

Should we revisit anticoagulation guidelines during thyroid storm?

Thyroid storm is a rare but potentially catastrophic disease expression of thyrotoxicosis with well-recognized cardiovascular manifestations such as heart failure and atrial fibrillation. Even through some studies have found an increased risk of cardiac thrombus formation and subsequent thromboembolism in these patients, the use of anticoagulation to prevent thromboembolic sequelae of thyrotoxic atrial fibrillation remains unclear. We present a patient presenting with new onset dilated cardiomyopathy and resistant atrial fibrillation with thyroid storm that had a large left atrial appendage clot. Case particulars are discussed and the literature reviewed.