Graves' Disease Exacerbation with Impending Thyroid Storm After SARS-CoV-2 Infection: A Case Report.

BACKGROUND Since the COVID-19 pandemic, several cases of COVID-19 have been linked to the development of autoimmune disorders, including of the thyroid. Graves' disease (GD) is a rare complication that can occur following SARS-CoV-2 infection. Reports have linked COVID-19 to new onset and exacerbation of GD. We present a case of a 42-year-old woman with a history of GD presenting with impending thyroid storm 3 weeks following a diagnosis of COVID-19. CASE REPORT A 42-year-old woman with a history of GD presented to the Emergency Department (ED) for an acute exacerbation of hyperthyroidism 3 weeks after SARS-CoV-2 infection was diagnosed on a home test. Symptoms included daily headaches, increased bilateral eye pressure, fatigue, muscle weakness, episodes of confusion and agitation, persistent heart palpitations, and goiter. Elevated free T4 of 5.57, free T3 of 15.68, total T3 of 4.43, and near-absent thyroid stimulating hormone were noted. The Burch-Wartofsky scale was 40, which was concerning for an impending thyroid storm; however, at the time of admission, she was not in a thyroid storm. Treatment included propylthiouracil, potassium iodide oral solution, and propranolol, with symptom improvement. Due to prior history of intolerance to antithyroid medications and recent exacerbation, a thyroidectomy was performed once she was in a euthyroid state. CONCLUSIONS Our case demonstrates the importance of recognizing COVID-19 as an etiology or a trigger for new onset or exacerbation of GD. Our case highlights that being vigilant to recognize the association between COVID-19 and thyroid abnormalities for early diagnosis and treatment is imperative.

Severe autoimune thyreotoxicosis complicated by febrile neutropenia as a result of thyreostatic therapy.

Hyperthyreoidism is a clinical manifestation of excessive production of thyroid hormones. In most cases pacient ´s condition allows ambulant treatment. Rarely, it can develop into an acute, life- threatening thyrotoxic crisis which has to be treated in the intensive care unit. Main therapy includes antithyroid medication, corticosteroids, beta- blockers and rehydratation, mostly parenteral. If initial treatment fails, plasmapheresis provides effective strategy. Antithyroid medication may come with side effects as rash, digestive issues, joint pain.Agranulocystosis or acute liver lesion which leads to liver failure belong among the most severe ones. In this case we report a pacient with thyrotoxic crisis, atrial fibrilation which led to ventricular fibrilation, cor thyreotoxicum. The treatment was complicated by febrile neutropenia.

Thyroid storm induced by combined nivolumab and ipilimumab immunotherapy in advanced non-small cell lung cancer.

Thyroid storm is a rare and life-threatening condition associated with excess thyroid hormones. Early detection of thyroid storm is the key to decreasing the morbidity and mortality associated with this condition. We present a rare case of thyroid storm induced by combination therapy with nivolumab and ipilimumab in a patient with advanced non-small cell lung cancer (NSCLC). Because of prominent hyperthyroidism with gastrointestinal symptoms and signs of heart failure, the patient was diagnosed with thyroid storm 3 weeks after initiating this combination immunotherapy. The patient had no history of thyroid disease but was positive for antithyroid antibodies. This case report suggests that thyroid function and symptoms of suspected thyroid storm should be evaluated routinely within 3 weeks from the initiation of therapy when combination therapy is administered in patients with NSCLC positive for antithyroid antibodies.

Clinical Review and Update on the Management of Thyroid Storm.

Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves' disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis. The purpose of this article is a clinical review of the various treatments and methodologies to achieve a euthyroid state in patients with thyroid storm prior to definitive therapy.

Postoperative thyroid crisis in an 11-year old male with McCune-Albright syndrome and atypical triiodothyronine hyperthyroidism: A case report.

RATIONALE: McCune-Albright syndrome (MAS) is a rare heterogeneous clinical disease caused by sporadic, somatic, and postzygotic mutations. Thyroid crisis is even rare in patients with MAS, and we report the clinical outcomes of the first case of a MAS patient with atypical triiodothyronine (T3) hyperthyroidism who developed thyroid crisis after orthopedic surgery. PATIENT CONCERNS: The patient with MAS and atypical T3 hyperthyroidism was an 11-year-old man who had undergone surgery for a right femur fracture and shepherd bending deformity. His main symptoms were dizziness, nausea, and vomiting with elevated body temperature because of developed thyroid crisis. Thyroid function tests showed high T3 and remarkably high free T3 levels, and remarkably increased thyrotropin level, but unchanged thyroxine and free thyroxine levels. DIAGNOSIS: The patient was diagnosed with postoperative thyroid crisis following surgery for a right femur fracture, shepherd bending deformity, and MAS with atypical T3 hyperthyroidism. INTERVENTIONS: Propranolol was intravenously administered. The therapy included intravenous hydrocortisone, a saturated solution of potassium iodine and propylthiouracil, and continuous physical cooling. OUTCOMES: The patient was discharged after achieving a stable condition with normal thyroid and liver function after surgery because of active anti-thyroid crisis treatment. LESSONS: The operation of such patients should focus on the pre-operative heart rate, platelet level, and thyroid hormone levels. Abnormal values should be adjusted to the normal range, and such patients should achieve complete hemostasis and transfuse with blood following surgery anemia.

Increased Ileostomy Output as an Indicator of Thyroid Storm in a Patient without an Established History of Underlying Thyroid Disease.

BACKGROUND Thyroid storm, also known as thyrotoxic crisis, is a rare but life-threatening endocrine emergency that presents with multisystem involvement. Patients present with pronounced signs of hyperthyroidism, fever, tachycardia, and differing severities of multisystem dysfunction and decompensation. Early recognition and prompt initiation of treatment are important. The development of thyroid storm in patients with no established history of underlying hyperthyroidism is rare. CASE REPORT In this case report, we describe the occurrence of thyroid storm in a 27-year-old man without an established history of underlying thyroid disease, who was admitted to the Intensive Care Unit (ICU) with a high ileostomy output and fever. Although initially treated for possible sepsis, the diagnosis of thyroid storm was made only after a thorough workup was initiated and he was found to have underlying Graves' disease. Prompt treatment resulted in the resolution of symptoms and avoided potential morbidity and mortality. CONCLUSIONS This case highlights the potential difficulty in diagnosing thyroid storm in a patient admitted to the ICU without an established history of hyperthyroidism. Upgrade in care, timely diagnosis, and initiation of appropriate therapy led to a favorable outcome. Clinicians should consider hyperthyroidism as a possible cause of high ileostomy output, especially when it does not resolve with traditional treatment and no obvious cause can be identified. This case demonstrates the challenges presented when the patient's history and clinical signs are ambiguous and stresses the importance of "outside the box" thinking.

Thyroid crisis caused by metastatic thyroid cancer: an autopsy case report.

BACKGROUND: Thyroid crisis is a life-threatening condition in thyrotoxic patients. Although differentiated thyroid cancer is one of the causes of hyperthyroidism, reports on thyroid crisis caused by thyroid cancer are quite limited. Here, we describe a case of thyroid crisis caused by metastatic thyroid cancer. CASE PRESENTATION: A 91-year-old woman was admitted to our hospital because of loss of appetite. Two years prior to this hospitalization, she presented with subclinical thyrotoxicosis and was diagnosed with histologically unidentified thyroid cancer with multiple metastases, and she refused aggressive medical interventions. On admission, she exhibited extreme thyrotoxicosis, and the presence of fever, severe tachycardia, impaired consciousness, and heart failure revealed the presence of thyroid crisis. All thyroid autoantibodies were negative. Multidisciplinary conservative treatment was initiated; however, she died on the fifth day after admission. Autopsy revealed the presence of primary anaplastic thyroid carcinoma and multiple metastatic foci arising from follicular thyroid carcinoma. Both primary and metastatic follicular thyroid carcinoma likely induced thyrotoxicosis, which could have been exacerbated by anaplastic thyroid carcinoma. CONCLUSIONS: Even though the trigger of thyroid crisis in this patient is not clear, the aggravated progression of her clinical course suggests that careful monitoring of thyroid hormones and appropriate intervention are essential for patients with thyroid cancer.

Postoperative Thyroid Storm After Evacuation of a Complete Hydatidiform Mole: A Case Report.

Gestational trophoblastic disease can lead to excess thyroid hormone release and rarely, thyroid storm. We present a case of complete molar pregnancy with hyperthyroidism that was not identified or treated before surgical evacuation of uterine contents. Untreated hyperthyroidism preoperatively led to unanticipated thyroid storm immediately after emergence from anesthesia. It is important for anesthesia providers to recognize the link between gestational trophoblastic disease and thyrotoxicosis, and appreciate the severe consequences than can occur if left untreated. Anesthesia providers should strongly consider preoperative consultation and treatment. Being prepared to treat intraoperative symptoms and thyroid storm is paramount.

Pediatric volvulus induced thyroid storm.

Thyroid storm is an unusually rare but life-threatening pediatric occurrence, carrying significant mortality. Skewed towards the adolescent population, thyroid decompensation occurs due to inciting factors ranging from infection, trauma, surgery, burns, medications, direct thyroid trauma, and rarely volvulus. Emergent care focuses on both reversing the inciting event as well as quelling the metabolic hyperactivity associated with thyroid storm. In review of the available literature, this case is the first to date of thyroid storm secondary to malrotation with midgut volvulus in a previously euthyroid adolescent patient.

Thyroid storm in a dog secondary to thyroid carcinoma.

OBJECTIVE: To describe the clinical presentation, clinical course, and management of a dog with thyroid storm (TS) secondary to a functional thyroid carcinoma. CASE SUMMARY: A 12-year-old neutered female Golden Retriever was evaluated for severe weight loss, hyperthermia, and tachycardia. The dog had a ventral neck mass and markedly increased thyroxine concentration. Cervical ultrasound showed a suspected left thyroid mass with invasion into the jugular vein. Despite aggressive therapy, the patient progressed to a clinical TS. Postmortem examination was supportive of the clinical diagnosis. NEW OR UNIQUE INFORMATION PROVIDED: To the authors' knowledge, this is the first report of TS in a dog.

Delayed diagnosis of dilated thyrotoxic cardiomyopathy with coexistent multifocal atrial tachycardia: a case report.

BACKGROUND: Thyroid storm (TS) is a rare but potentially life-threatening sequelae of untreated or undertreated hyperthyroidism. While TS frequently causes high-output heart failure, low-output heart failure related to dilated cardiomyopathy (DCM) is extremely rare. Tachycardia is a common clinical presentation of TS, and ß1-selective blockers are the first-line agents for treating TS-associated tachycardia. However, given that ß-blockers have negative chronotropic and negative inotropic effects, amiodarone may be safe and effective for the treatment of TS-induced tachyarrhythmia in patients with moderate to severe heart failure. While long-term amiodarone administration causes hypothyroidism, or less frequently, hyperthyroidism, little is known about the effects of short-term amiodarone administration on thyroid function. CASE PRESENTATION: A 31-year-old healthy woman presented with worsening dyspnoea. She was tachycardic with multifocal atrial tachycardia (MAT) of 184 beats/min, confirmed by electrocardiogram. Echocardiographic findings were consistent with DCM, with an ejection fraction of 20%. Thus, she was initially diagnosed with acute heart failure due to DCM with coexistent MAT. Tachycardia persisted despite cardioversion attempts and treatment with multiple anti-arrhythmic drugs. Consequently, she rapidly progressed to cardiogenic shock and respiratory decompensation, which required intubation and an intra-aortic balloon pump support. Moreover, the undiagnosed Graves' disease, lack of suspicion, and postponed analysis of thyroid function tests led to a delayed diagnosis of TS. Amiodarone, which was initiated for MAT, unexpectedly ameliorated thyrotoxicosis, resulting in a euthyroid state and the patient's significantly improved condition and cardiac function. She was discharged on day 40. Finally, she underwent total thyroidectomy; thyroid pathology was consisting with Graves' disease. Her postoperative course was uneventful. CONCLUSIONS: Herein, we describe a case of delayed diagnosis of dilated thyrotoxic cardiomyopathy with coexistent MAT. The patient required intensive care due to the catastrophic sequelae and was successfully treated with amiodarone. This is the first case report of TS-associated MAT and highlights the clinical importance of high suspicion of TS in de novo heart failure with any tachyarrhythmia or DCM of unknown etiology and the potential effects of short-term amiodarone administration in the treatment of TS.

Thyroid storm obscured by acute asthma exacerbation and concurrent H1N1 influenza.

We present an uncommon case of H1N1 triggered thyroid storm in a patient with previously undiagnosed Grave's Disease. This case illustrates the challenges of diagnosing thyroid storm in the emergency department and the importance of including it in the differential when treating more common diagnoses that fail to respond to usual therapies. Thyroid storm is an endocrinologic emergency and requires prompt recognition and treatment. However, it remains a diagnostic challenge as there is no laboratory test specific to thyroid storm. Diagnosis relies on clinical suspicion in corroboration with patient presentation, laboratory findings and response to therapy.

Neonatal thyroid storm: the importance of an accurate antenatal history.

A near-term infant became unwell immediately after birth with cardiorespiratory compromise-persistent tachycardia, pulmonary hypertension and reduced cardiac function. There had been no concerns during the pregnancy and the obstetrical and maternal medical history was unremarkable apart from hypothyroidism. A thyroid function test on admission revealed a significantly elevated free T4 and a diagnosis of a thyroid storm was made. On questioning it became apparent that she had Graves' disease after her last pregnancy and was rendered hypothyroid post surgery, she was not aware of the relevance of this at her booking visit. This case highlights the importance of monitoring of women who have a history of a diagnosis of Graves' disease, regardless of thyroid function status, to allow for appropriate antenatal monitoring, preparedness of the NICU (neonatal intensive care unit) team and correct follow-up of the neonate. It also demonstrates the importance of ensuring a patient is properly educated about their condition.

Thyroid storm after mitral valve repair in a patient with Becker muscular dystrophy.

A 40-year-old male with Becker muscular dystrophy presented with severe mitral regurgitation and underwent mitral valve repair. Following the surgery, the patient became tachycardic and developed a continuous high-grade fever and hyperbilirubinemia. The patient's condition worsened and we eventually tested his thyroid levels and discovered abnormally high thyroid levels. After diagnosing a severe thyroid storm, the patient was treated with oral administration of Lugol's iodine and thiamazole, as well as an intravenous steroid, which led to an immediate improvement of symptoms. The incidence of thyroid storm after open-heart surgery is extremely rare but highly life-threatening if unrecognized.

Sepsis and thyroid storm in a patient with methimazole-induced agranulocytosis.

Paediatric hyperthyroidism cases are mostly caused by Grave's disease. Thyroid storm is a life-threatening condition seen rarely, in severe thyrotoxicosis, occurring in about 1%-2% of patients with hyperthyroidism. Antithyroid medications and beta-blockers are typically the first-line management of thyroid storm. We report a challenging case of a 15-year-old girl who presented with thyroid storm in the setting of septic shock and methimazole-induced agranulocytosis. Since the first-line agents were contraindicated, plasmapheresis was used to control the thyroid storm and as a bridging therapy to the definitive therapy of early thyroidectomy. This is the first paediatric case report that outlines the use of plasmapheresis in the management of complicated thyrotoxicosis in a setting of septic shock.

Thyroid storm after coronary artery bypass surgery: a case report.

BACKGROUND: Thyroid storm is a rare, life-threatening disease triggered by an acute event or trauma, such as surgery of the thyroid or another area, and infection. However, recent studies have shown that irregular use or discontinuation of antithyroid drugs is the most common cause of thyroid storm. A cardiovascular event caused by thyroid storm following coronary artery bypass graft (CABG) is high output heart failure with extreme tachycardia, which can be fatal. Thyroid storm after nonthyroidal surgery, especially CABG, has been rarely reported, with only one reported case until now. Herein, we present a case of thyroid storm onset in a patient who underwent CABG. CASE PRESENTATION: A 74-year-old woman with a history of antithyroid medication discontinuation against medical advice underwent urgent CABG. The patient exhibited extreme tachycardia postoperatively, which is highly suggestive of thyroid storm. Although a higher infection risk is an important consideration, a high-dose steroid was used to control the intractable tachycardia that did not respond to beta-blocker administration. Despite appropriate antibiotic treatment, the patient's condition was exacerbated, and she developed multiple organ failure resulting from adult respiratory distress syndrome progression, and she died on day 8 after surgery. CONCLUSIONS: Risk factors for thyroid storm after CABG and its treatment outcomes are rarely reported. Patients with a history of inappropriate antithyroid medication prescription should be in a euthyroid state before surgery. If surgery is imminent, anticipating thyroid storm and its treatment as well as a euthyroid state can improve recovery outcomes postoperatively.

Candida tropicalis Thyroiditis Presenting With Thyroid Storm in a Pediatric Patient With Acute Lymphocytic Leukemia.

Suppurative thyroiditis is uncommon in the pediatric population and particularly rare to be caused by fungi. We present a case of Candida tropicalis thyroiditis in an adolescent male with acute lymphocytic leukemia that led to disseminated candidiasis, thyroid storm and eventual total thyroidectomy for source control.

Severe Myasthenic Manifestation of Leptospirosis Associated with New Sequence Type of Leptospira interrogans.

We report the rapid development of a myasthenic crisis as the first-time manifestation of myasthenia gravis. The symptoms developed in the course of acute leptospirosis associated with a new sequence type of Leptospira interrogans. Antibiotic treatment led to rapid amelioration of myasthenia.

Review article: Non-fatal strangulation: Hidden injuries, hidden risks.

Non-fatal strangulation (NFS) can be a cause of severe injury. However, the prevalence and rates of injuries from NFS are unknown, as few victims present to medical attention after strangulation. As up to 40% of fatal strangulations have no external signs, and the majority of surviving victims have few or minor injuries, finding those people severely injured remains challenging. The majority of the evidence regarding NFS is largely based on case reports and case series with no robust studies estimating rates of injuries or the best investigation tools. The injuries that are reported make clear that strangulation is a potentially lethal form of injury that should not be ignored in those presenting having been strangled, or in those presenting with neurological symptoms, including strokes, seizures and vascular abnormalities. The safety implications of strangulation are also important as it can be a prelude to homicide. A search of the literature was carried out with the following terms: Nonfatal strangulation (10), Nonfatal strangulation (17), 'Strangulation injuries' (19), 'Manual strangulation' (92) - laboratory testing eliminated, and 'choking game'. The PubMed database was used first, followed by the collections of Monash University and the Strangulation Institute (as some articles were too old to find electronically). This article summarises the injuries that can occur following strangulation and discusses the quality of the evidence thus far.