Abstract
Thyroid emergencies are uncommon. However, given the systemic effects of thyroid hormone, dysfunction from severe hypothyroidism or severe thyrotoxicosis requires prompt diagnosis and management on intensive care unit. Both myxedema coma and thyroid storm are clinical diagnoses in which lack of timely therapy can result in fatal consequences. History and physical exam are cornerstones to establishing diagnosis with low threshold to suspect infection as a potential trigger event especially in the immunosuppressed cancer patient. In addition to close observation of cardiorespiratory status, antithyroid drugs for thyroid storm and levothyroxine treatment for myxedema coma, both emergent scenarios require empirical coverage with glucocorticoids until adrenal insufficiency is ruled out. Careful review of medications is important as newer chemotherapeutic agents like tyrosine kinase inhibitors and immune checkpoint inhibitors are known to cause thyroid dysfunction. There are many challenges in interpreting thyroid function tests in the setting of acute illness as patients can present with transient test abnormalities denominated as euthyroid sick syndrome or non-thyroidal illness syndrome (NTIS), which is a physiologic adaptation of the hypothalamic-pituitary-thyroid axis.
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References
Akamizu T. Thyroid storm: a Japanese perspective. Thyroid. 2018;28(1):32–40. https://doi.org/10.1089/thy.2017.0243.
Akamizu T, Satoh T, Isozaki O, Suzuki,A, Wakino S, Iburi T, … Japan Thyroid A. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys.[Erratum appears in Thyroid. 2012;22(9):979]. Thyroid. 2012;22(7):661–679. https://doi.org/10.1089/thy.2011.0334
Alfadhli E, Gianoukakis AG. Management of severe thyrotoxicosis when the gastrointestinal tract is compromised. Thyroid. 2011;21(3):215–20. https://doi.org/10.1089/thy.2010.0159.
Alswat KA. Role of cholestyramine in refractory hyperthyroidism: a case report and literature review. Am J Case Rep. 2015;16:486–90. https://doi.org/10.12659/AJCR.893821.
Arlot S, Debussche X, Lalau JD, Mesmacque A, Tolani M, Quichaud J, Fournier A. Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care Med. 1991;17(1):16–8.
Barroso-Sousa R, Barry WT, Garrido-Castro AC, et al. Incidence of endocrine dysfunction following the use of different immune checkpoint inhibitor regimens: a systematic review and meta-analysis. JAMA Oncol. 2018;4(2):173–82. https://doi.org/10.1001/jamaoncol.2017.3064.
Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metabol Clin North Am. 1993;22(2):263–77.
Carhill A, Gutierrez A, Lakhia R, Nalini R. Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis. BMJ Case Rep. 2012; https://doi.org/10.1136/bcr-2012-006696.
Chakraborty S, Fedderson J, Gums JJ, Toole A. Amiodarone-induced myxedema coma – a case and review of the literature. Arch Med Sci. 2014;10(6): 1263–7. https://doi.org/10.5114/aoms.2013.35026.
Chaudhari D, Gangadharan V, Forrest T. Heart failure presenting as myxedema coma: case report and review article. [Republished in Tenn Med. 2014; 107(2):39–41; PMID: 24592692]. Tenn Med. 2013; 106(5):39–40.
Chen SY, Kao PC, Lin ZZ, Chiang WC, Fang CC. Sunitinib-induced myxedema coma. Am J Emerg Med. 2009;27(3):370.e371–3. https://doi.org/10.1016/j.ajem.2008.07.012.
Chen T-S, Wen M-J, Hung Y-J, Hsieh C-H, Hsiao F-C. A rare storm in a psychiatric ward: thyroid storm. Gen Hosp Psychiatry. 2012;34(2):210.e211–4. https://doi.org/10.1016/j.genhosppsych.2011.08.013.
Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. J Intensive Care Med. 2015;30(3):131–40. https://doi.org/10.1177/0885066613498053.
Chopra IJ. Euthyroid sick syndrome: is it a misnomer? J Clin Endocrinol Metabol. 1997;82(2):329–34. https://doi.org/10.1210/jcem.82.2.3745.
Cooper DS. Antithyroid drugs. N Engl J Med. 1984;311(21):1353–62. https://doi.org/10.1056/nejm198411223112106.
de Vries EM, Fliers E, Boelen A. The molecular basis of the non-thyroidal illness syndrome. J Endocrinol. 2015;225(3):R67–81. https://doi.org/10.1530/joe-15-0133.
Eliades M, El-Maouche D, Choudhary C, Zinsmeister B, Burman KD. Takotsubo cardiomyopathy associated with thyrotoxicosis: a case report and review of the literature. Thyroid. 2014;24(2):383–9. https://doi.org/10.1089/thy.2012.0384.
Fliers E, Bianco AC, Langouche L, Boelen A. Thyroid function in critically ill patients. Lancet Diabetes Endocrinol. 2015;3(10):816–25. https://doi.org/10.1016/s2213-8587(15)00225-9.
Fliers E, Wiersinga WM. Myxedema coma. Rev Endocr Metab Disord. 2003;4(2):137–41.
Grais IM, Sowers JR. Thyroid and the heart. Am J Med. 2014;127(8):691–8. https://doi.org/10.1016/j.amjmed.2014.03.009.
Hampton J. Thyroid gland disorder emergencies: thyroid storm and myxedema coma. AACN Adv Crit Care. 2013;24(3):325–32. https://doi.org/10.1097/NCI.0b013e31829bb8c3.
Hatch DM, Roy RC. Cancer and deliberate hypothyroidism, anesthesia, and myxedema coma: the curse of oncologic outcomes based on hypothyroidism. J Clin Anesth. 2013;25(1):1–3. https://doi.org/10.1016/j.jclinane.2012.11.002.
Idrose AM. Acute and emergency care for thyrotoxicosis and thyroid storm. Acute Med Surg. 2015;2(3):147–57. https://doi.org/10.1002/ams2.104.
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(12):1283–6. https://doi.org/10.1089/thy.2011.0353.
Jongjaroenprasert W, Akarawut W, Chantasart D, Chailurkit L, Rajatanavin R. Rectal administration of propylthiouracil in hyperthyroid patients: comparison of suspension enema and suppository form. Thyroid. 2002;12(7):627–31. https://doi.org/10.1089/105072502320288500.
Kaykhaei MA, Shams M, Sadegholvad A, Dabbaghmanesh MH, Omrani GR. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine. 2008;34(1):52–5. https://doi.org/10.1007/s12020-008-9107-5.
Klein I, Danzi S. Thyroid disease and the heart. Curr Probl Cardiol. 2016;41(2):65–92. https://doi.org/10.1016/j.cpcardiol.2015.04.002.
Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin N Am. 2012;96(2):385–403. https://doi.org/10.1016/j.mcna.2012.01.015.
Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007;22(4):224–31.
Lin YQ, Wang X, Murthy MS, Agarwala S. Life-threatening thyrotoxicosis induced by combination therapy with peg-interferon and ribavirin in chronic hepatitis c. Endocr Pract. 2005;11(2):135–9. https://doi.org/10.4158/ep.11.2.135.
Mancano MA. Sorafenib-induced thyroid storm; ceftaroline-induced eosinophilic pneumonia; imatinib-induced osteonecrosis of the tibia; visual and auditory hallucinations with citalopram. Hosp Pharm. 2014;49(2):121–6. https://doi.org/10.1310/hpj4902-121.
Martinez-Diaz GJ, Formaker C, Hsia R. Atrial fibrillation from thyroid storm. J Emerg Med. 2012;42(1):e7–9. https://doi.org/10.1016/j.jemermed.2008.06.023.
Mathes DD. Treatment of myxedema coma for emergency surgery. Anesth Analg. 1998;86(2):450–1.
Mathew V, Misgar RA, Ghosh S, Mukhopadhyay P, Roychowdhury P, Pandit K, … Chowdhury S. Myxedema coma: a new look into an old crisis. J Thyroid Res. 2011;2011:493462. https://doi.org/10.4061/2011/493462
Mavroson MM, Patel N, Akker E. Myxedema psychosis in a patient with undiagnosed Hashimoto thyroiditis. J Am Osteopath Assoc. 2017;117(1): 50–4. https://doi.org/10.7556/jaoa.2017.007.
McMillen B, Dhillon MS, Yong-Yow S. A rare case of thyroid storm. BMJ Case Rep. 2016; https://doi.org/10.1136/bcr-2016-214603.
Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metabol Clin North Am. 2006;35(4):663–86, vii
Ngo AS-Y, Lung Tan DC. Thyrotoxic heart disease. Resuscitation. 2006;70(2):287–90. https://doi.org/10.1016/j.resuscitation.2006.01.009.
Noh KW, Seon CS, Choi JW, Cho YB, Park JY, Kim HJ. Thyroid storm and reversible thyrotoxic cardiomyopathy after ingestion of seafood stew thought to contain marine neurotoxin. Thyroid. 2011;21(6): 679–82. https://doi.org/10.1089/thy.2010.0276.
Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: analysis of a national inpatient database in Japan. J Epidemiol. 2017;27(3):117–22. https://doi.org/10.1016/j.je.2016.04.002.
Papi G, Corsello SM, Pontecorvi A. Clinical concepts on thyroid emergencies. Front Endocrinol. 2014;5:102. https://doi.org/10.3389/fendo.2014.00102.
Popoveniuc G, Chandra T, Sud A, Sharma M, Blackman MR, Burman KD, … Wartofsky L. A diagnostic scoring system for myxedema coma. Endocr Pract, 2014;20(8):808–817. https://doi.org/10.4158/EP13460.OR.
Rodriguez I, Fluiters E, Perez-Mendez LF, Luna R, Paramo C, Garcia-Mayor RV. Factors associated with mortality of patients with myxoedema coma: prospective study in 11 cases treated in a single institution. J Endocrinol. 2004;180(2):347–50.
Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, … Walter MA. 2016 American thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343–1421. https://doi.org/10.1089/thy.2016.0229.
Sahoo JP, Selviambigapathy J, Kamalanathan S, Nagarajan K, Vivekanandan M. Effect of steroid replacement on thyroid function and thyroid autoimmunity in Addison’s disease with primary hypothyroidism. Ind J Endocrinol Metabol. 2016;20(2): 162–6. https://doi.org/10.4103/2230-8210.176356.
Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, … 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(12):1025–1064. https://doi.org/10.1507/endocrj.EJ16-0336.
Shaked Y, Samra Y, Zwas ST. Graves’ disease presenting as pyrexia of unknown origin. Postgrad Med J. 1988;64(749):209–12.
Spittle L. Diagnoses in opposition: thyroid storm and myxedema coma. AACN Clin Issues Crit Care Nurs. 1992;3(2):300–8.
Tietgens ST, Leinung MC. Thyroid storm. Med Clin N Am. 1995;79(1):169–84.
Tokushima Y, Sakanishi Y, Nagae K, Tokushima M, Tago M, Tomonaga M, … Yamashita S-I. Thyroid storm complicated by Bicytopenia and disseminated intravascular coagulation. Am J Case Rep. 2014;15:312–316. https://doi.org/10.12659/AJCR.890519.
Tsai WC, Pei D, Wang TF, Wu DA, Li JC, Wei CL, … Kuo SW. The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves’ hyperthyroidism. Clin Endocrinol. 2005;62(5):521–524. https://doi.org/10.1111/j.1365-2265.2005.02249.x.
Umezu T, Ashitani K, Toda T, Yanagawa T. A patient who experienced thyroid storm complicated by rhabdomyolysis, deep vein thrombosis, and a silent pulmonary embolism: a case report. BMC Res Notes. 2013;6:198. https://doi.org/10.1186/1756-0500-6-198.
Van den Berghe G. Non-thyroidal illness in the ICU: a syndrome with different faces. Thyroid. 2014;24(10): 1456–65. https://doi.org/10.1089/thy.2014.0201.
Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. 2000;62(11):2485–90.
Walter RM, Bartle WR. Rectal administration of propylthiouracil in the treatment of graves’ disease. Am J Med. 1990;88(1):69–70. https://doi.org/10.1016/0002-9343(90)90130-6.
Warner MH, Beckett GJ. Mechanisms behind the non-thyroidal illness syndrome: an update. J Endocrinol. 2010;205(1):1–13. https://doi.org/10.1677/joe-09-0412.
Wartofsky L. Myxedema coma. Endocrinol Metabol Cli North Am. 2006;35(4):687–98, vii–viii
Wartofsky L. Clinical criteria for the diagnosis of Thyroid storm. Thyroid. 2012;22(7):659–60. https://doi.org/10.1089/thy.2012.2207.ed1.
Wiersinga WM, Duntas L, Fadeyev V, Nygaard B, Vanderpump MP. 2012 ETA guidelines: the use of L-T4 + L-T3 in the treatment of hypothyroidism. Eur Thyroid J. 2012;1(2):55–71. https://doi.org/10.1159/000339444.
Wilson BE, Hobbs WN. Case report: pseudoephedrine-associated thyroid storm: thyroid hormone-catecholamine interactions. Am J Med Sci. 1993;306(5):317–9.
Yamamoto T, Fukuyama J, Fujiyoshi A. Factors associated with mortality of myxedema coma: report of eight cases and literature survey. Thyroid. 1999;9(12):1167–74.
Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid. 1995;5(5): 403–5. https://doi.org/10.1089/thy.1995.5.403.
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Agosto, S., Thosani, S. (2019). Thyroid Emergencies in Critically Ill Cancer Patients. In: Nates, J., Price, K. (eds) Oncologic Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-74698-2_83-1
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