A Case of Graves' Disease That Was Misdiagnosed as Thyrotoxic Crisis because of Chronic Bromvalerylurea Intoxication / 日本プライマリ・ケア連合学会誌

A woman in her 50s presented to the hospital with a chief complaint of headache and nausea. Graves' disease was diagnosed based on positive blood test results for thyrotoxicosis and TSH receptor antibody and ultrasonographic thyroid gland findings. The patient was hospitalized and started treatment with thiamazole; however, after hospitalization, psychiatric symptoms, such as visual and auditory hallucinations, appeared, and she fulfilled the diagnostic criteria for thyroid crisis. We increased the dose of thiamazole and added potassium iodide. Thyroid function improved; however, the patient experienced reemergence of psychiatric symptoms. Blood tests revealed pseudohyperchloremia, which led to the discovery of abuse of over-the-counter analgesics containing bromwarelyl urea. The psychiatric symptoms were suspected to be due to withdrawal from chronic bromine intoxication. After starting psychotropic drugs, the patient's psychiatric symptoms became mild, her thyroid function continued to improve steadily, and she was discharged from the hospital. Thyroid crisis is a condition that should be suspected and treated at an early stage; however, the diagnostic criteria for thyroid crisis can be false-positive if the thyroid disease is accompanied by other conditions that cause psychiatric symptoms.

Tormenta tiroidea / Thyroid storm

La tormenta tiroidea es una de las situaciones más críticas entre las emergencias endocrinas y tiene una significativa mortalidad. La etiología más común de tirotoxicosis es la enfermedad de Graves y el factor precipitante que predomina es la infección. Clínicamente se caracteriza por la disfunción de varios sistemas (termorregulador, nervioso central, gastrointestinal y cardiovascular), con niveles de hormonas tiroideas libres o totales por encima de los valores normales. El tratamiento debe tener un enfoque multidisciplinario, e incluye medidas de soporte en unidades de cuidados intensivos, normalización de la temperatura corporal, reducción de la producción y liberación de hormonas tiroideas, con antitiroideos de síntesis y yodo respectivamente, bloqueo de los efectos periféricos mediante la administración de beta-bloqueadores, y corrección del factor desencadenante. Una vez que el paciente se encuentra estable es necesario planificar una terapia definitiva que impida la recurrencia futura de la crisis tirotóxica(AU)

The thyroid storm is one of the most critical situations in the endocrine emergencies and exhibits a significant mortality rate. The most common etiology of thyrotoxicosis is Graves' disease and the predominant precipitating factor is infection. The clinical characteristics are dysfunction of several systems (heat-regulator, central nervous, gastrointestinal and cardiovascular), and levels of total or free thyroid hormones that exceed the normal values. The treatment must be multidisciplinary and include support measures in intensive care units, normalization of body temperature, reduction of the production and the release of thyroid hormones by using synthesis and iodine anti-thyroid products respectively, blockade of the peripheral effects through administration of Beta-blockers and correction of the unleashing factor. Once the patients are stabilized, it is necessary to plan the final therapy that will prevent the future recurrence of the thyrotoxic crisis(AU)

Thyrotoxic Crisis in Graves' Patient with Severe Uncontrolled DM during Surgery: One case report / 대한마취과학회지

Thyrotoxic crisis is a medical emergency with an associated mortality of 10-75%. It is usually encountered in patients with poorly controlled or undiagnosed Graves' disease. The occurrence of thyrotoxic crisis is rare due to routine function tests, which enable a diagnosis to be made even in its subclinical form. However, a thyrotoxic crisis can develop rapidly and bears little relationship to circulating thyroid hormone levels. We present a case of a thyrotoxic crisis in a 52-year-old woman, whose emergent thyroid function tests revealed a near normal euthyroid level. Her Hb A1c was 10.5% before the operation.

Development of Thyrotoxic Crisis during the Treatment of Postherpetic Neuralgia / 대한마취과학회지

Thyrotoxic crisis is a life-threatening exacerbation of hyperthyroidism seen during periods of stress, which requires early recognition and adequate treatment. A 52-year-old female who suffered from severe right thoracic pain due to postherpetic neuralgia with hyperthyroidism, has been initially treated with antiviral agent and anticonvulsant in the department of neurology. She was transfered to our pain clinic because of uncontrolled severe pain. In our pain clinic, continuous thoracic epidural administration of bupivacaine and clonidine and oral analgesic medications produce visual analog scale from 8-9 to 5-6. She was admitted because of partially controlled pain and she was performed intercostal neurolysis with 10% phenol. As a result, visual analog scale was decreased from 5-6 to 2-3. After 3 days admission, extreme irritability, delirium, tachypnea, mild fever and tachycardia(heart rate: 160-180/min) were developed suddenly. Three hours later of proper treatment with oxygen inhalation, rapid fluid administration, diazepam 10 mg injection and antithyroid drug medication, heart rate and consciousness were returned to normal. Thoracic sympathetic ganglion neurolysis with absolute alcohol was performed without any sequelaes for the treatment of remnant visceral pain. And then, she was discharged with the relief of pain. The purpose of the present report is to review our experience with the clinical manifestations and management of thyrotoxic crisis developed during the treatment of postherpetic neuralgia, and to review of the treatment of thyrotoxic crisis and postherpetic neuralgia.