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Thyroid stormThyroid storm

2008.11,102008.11,10

Presenter: RiPresenter: Ri

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DefinitionDefinition

HyperthyroidismHyperthyroidism Overproduction of hormone from the

thyroid gland Thyrotoxicosis

Any cause ofexcessive thyroid hormoneconcentration

Thyroid storm Extreme manifestation of thyrotoxicosis

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EtiologyEtiology

Graves disease (most common)

Solitary toxic adenoma or toxic multinodular goiter

Rare cause hypersecretory thyroid carcinoma thyrotropin-secreting pituitary adenoma

struma ovarii/teratoma

human chorionic gonadotropiasecreting hydatidiformmole.

Other causes interferon alpha

interleukin-2induced thyrotoxicosis

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Precipitating event

Systemic insults Surgery, trauma, myocardial infarction,

pulmonary thromboembolism, DKA, severeinfection

Discontinuation of antithyroid drugs

Excessive iodine (eg, radiocontrast dyes,

amiodarone) Radioiodine therapy

Pseudoephedrine and salicylate use

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Pathogenesis theory

Free T4Free T4 oo, but similar total T4, but similar total T4

oo target cell beta-adrenergic receptordensity

Postreceptor modifications in signalingpathways

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Clinical presentation

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Diagnosis

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> 45: highly suggesitve ; 25-44: impending storm;

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LABLAB

oo free T4 and free T3

qqTSHTSH

T3/ T4 ratio > 20:> 20: Graves disease and toxic nodular goiter

< 15:< 15: thyroiditis, iodine exposure

Hyperglycemia, hypercalcemia, elevated alkaline

phosphatase, leukocytosis, and elevated liverenzymes

CortisolCortisol oo (normal level(normal level adrenal insufficiency adrenal insufficiency))

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Radiologic imaging

CXR or chest CT (for infection)CXR or chest CT (for infection)

Nuclear medicine (o uptake)

Thyroid sonogram with Doppler flow

Enhanced flow

Secreting excessive hormones

Decreased flow

Subacute, postpartum, or silent thyroiditis

Exogenous causes of hyperthyroidism

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Electrocardiogram

Sinus tachycardia (40 %)

Atrial fibrillation (10-20 %)

> 60 y/o,

Underlying structural heart disease

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Management

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Multiple targets

Stopping synthesis of new hormone

Halting the release of stored thyroidhormone

Preventing conversion of T4 to T3

Controlling the adrenergic symptoms

Controlling systemic decompensationwith supportive therapy

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ThionamideThionamide

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SideeffectSideeffect

Common

Abnormal sense of taste, pruritus,

urticaria, fever, and arthralgias

Severe and rare

Agranulocytosis (0.35%, within 3 months)

Hepatotoxicity (0.1-0.2%) Vasculitis (more common in PTU)

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Iodine therapyIodine therapy

Wolff-Chaikoff effect

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Beta-blockade

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Glucocorticoids

Dexamethasone and hydrocortisone

Inhibit conversion of T4 to T3

In severe thyrotoxicosis with hypotension

100 mg Q8H

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Alternative therapies

Aplastic anemia andnephrotic syndrome

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Supportivecare/treatment

of precipitating cause Antipyretics (acetaminophen)

External cooling measures

Intravenous fluids with dextrose

Multivitamins, particularly thiamine

Antibiotics

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Perioperative management

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Preoperative management

Elective operation

Thionamide therapy

Iodine use may be indicated only ifthionamides cannot be tolerated

Emergent operation

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Definitive therapy

Iodine therapy can be discontinued

Glucocorticoids can be tapered

Thionamide gradually decreasing(weeks to months)

Beta-adrenergic receptor blockade

Radioactive iodine ablation

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Thanks for your attentionThanks for your attention

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Key wordsKey words

HyperthyroidismHyperthyroidism

Thyrotoxicosis

Thyroid storm