Multiorgan dysfunction in the perinatal patient

MODS is a rare but potentially lethal complication of pregnancy. Pregnancy induces physiologic changes in all major maternal organ systems that mimic early changes seen in SIRS and MODS. When a potentially life-threatening event occurs, such as hemorrhage,sepsis, or severe preeclampsia, the perinatal nurse must monitor subtle changes in maternal and fetal status and intervene to optimize maternal status.     

Hyperthyroidism and thyroid storm

Thyrotoxicosis and thyroid storm are disease states that result from thyroid hormone-induced hypermetabolism. The excess thyroid hormone is released from the thyroid gland as a result of excess thyroid hormone production, or by processes that disrupt the follicular structure of the gland with subsequent release of stored hormone. True hyperthyroidism results from increased synthesis and release of thyroid hormone and can be distinguished from other causes of thyrotoxicosis by the thyroid 131I uptake. Graves' disease is the most common cause of hyperthyroidism and occurs most often in women aged 30 to 50 years. The classic features of a patient with fully developed Graves' disease are difficult to overlook, but the clinical features of thyrotoxicosis vary with the etiology of the disease and the sensitivity of the patient's peripheral tissues. Thyroid storm presents with an exaggeration of the features of uncomplicated thyrotoxicosis and, in addition, an alteration in mental status. Thyroid storm may lead to irreversible cardiovascular collapse and death if proper treatment is not initiated in the Emergency Department. Specific therapy of hyperthyroidism follows several strategies, including inhibition of hormone synthesis and release, inhibition of peripheral conversion of T4 to T3, and blocking of the systemic effects of excess thyroid hormone. Treatments directed at these ends may be initiated rapidly in the emergency setting.     

Perfect storm: Therapeutic plasma exchange for a patient with thyroid storm

Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First‐line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8‐2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8‐1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.     

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.     

Coma and thyroid storm in apathetic thyrotoxicosis

We report the case of an 87-year-old woman with coma who was found to be in thyrotoxic crisis. The patient had a recent history of decreased mentation and apathy, and laboratory findings were found to be consistent with hyperthyroidism. After a stormy course, the clinical condition recovered to baseline, with return of laboratory values to normal following antithyroid therapy. We provide the details of this rarely documented presentation of apathetic hyperthyroidism with thyroid storm and coma and review the characteristics of similar cases in the literature.     

When the storm passes unnoticed--a case series of thyroid storm

INTRODUCTION: Thyroid crisis is an acute manifestation of thyrotoxicosis. Approximately 1-2% of patients progress to a thyroid storm, often precipitated by a physiologically stressful event. If unrecognized or left untreated, thyroid storm may result in cardiovascular collapse and death. AIM: We describe three patients who presented to the Emergency Department of Singapore General Hospital in a thyroid storm. They had complications of thyrocardiac disease with heart failure and arrhythmias. METHODS: An analysis of case records of patients presenting to the emergency department of Singapore General Hospital with a primary diagnosis of thyrotoxicosis was made over the period of 2004-2005. Three patients with thyroid storm were identified. All the patients presented heart failure and cardiac arrhythmias (1 atrial flutter, 2 atrial fibrillation). DISCUSSION AND CONCLUSION: Thyroid storm is a rare manifestation of thyrotoxicosis, usually occurring in females during the third to sixth decades of life. Serious complications such as heart failure and hypotension resulting in cardiovascular collapse and death may occur. Our case series consists of young males presenting with thyrocardiac failure. One patient was treated with beta-blockers and another with calcium channel blockers. Both developed cardiovascular collapse. The third patient was managed with digoxin with a good outcome. The current pathophysiology and therapeutic options are explored. A high index of suspicion should be maintained in young males presenting with heart failure and arrhythmia.     

Unrecognized thyroid dysfunction in patients with cancer

Abnormal thyroid function can cause subtle medical symptoms in "healthy" individuals. Because cancer can cause similar symptoms, physicians may fail to suspect and test for thyroid abnormalities. We measured thyroid function in 158 patients with various types of cancers being followed at a comprehensive cancer center and found that 16% of them had a thyroid abnormality, which had not been diagnosed and treated in any of them. We conclude that thyroid dysfunction is usually unrecognized in cancer patients and may possibly contribute to their morbidity.     

Not just gastroenteritis: thyroid storm unmasked

Establishing the diagnosis of thyroid storm is difficult in the ED, especially where there is no antecedent history of thyroid disease or clinical clues like goitre, exophthalmos or altered mentation, yet early recognition and treatment are essential in reducing mortality and morbidity from this endocrine emergency. We present a case where suspected infective gastroenteritis in a newly diagnosed diabetic masked the major symptomatology of thyroid storm, and review the diagnosis and management of thyrotoxic crisis.     

Intraoperative thyroid storm: a case report

An 18-year-old woman being treated for Graves disease underwent elective thyroidectomy. Tachycardia was noted before surgery. The patient's heart rate and temperature started to rise 30 minutes into surgery. Malignant hyperthermia was excluded on clinical grounds, and treatment with beta blockers was started. The patient's conditions stabilized, and surgery was completed. A review of the patient's laboratory test results revealed a high free thyroxine level before surgery. Diagnosis and management of thyroid storm are discussed.     

皮肌炎合并甲状腺功能异常的临床分析

目的 探讨合并甲状腺功能异常的皮肌炎（DM）患者临床及实验室检查特征.方法 回顾性分析112例DM患者,比较甲状腺功能异常组与正常组患者临床表现、实验室检查特点及死亡率差异.结果 112例DM患者中甲状腺功能异常者达48.2％,最常见表现为正常甲状腺病态综合征（ESS）（31.3％）,其次是甲状腺功能减退（简称甲减）（10.7％）和甲状腺功能亢进（简称甲亢）（6.3％）.与正常组相比,ESS组患者多见合并关节炎和间质性肺疾病（ILD）,也常出现C反应蛋白（C-reactive protein,CRP）、血清铁蛋白（ferritin,Fet）升高和血红蛋白（hemoglobin,HGB）降低（P均＜0.05）,且死亡率明显升高（P=0.006）.甲减组患者合并消化道受累比例、出现蛋白尿比例、IgM升高比例、甲状腺过氧化物酶抗体（thyroidperoxidase antibodies,TPOAb）阳性率、甲状腺球蛋白抗体（thyroglobulin antibodies,TGAb）阳性率均显著高于正常组（P均＜0.05）.甲亢组患者血浆胆固醇（cholesterol,CHO）水平明显升高（P＜0.05）.DM合并自身免疫性甲状腺疾病（AITD）发生率为5.4％,最常见类型为桥本甲状腺炎（HT）（3.6％）.结论 DM患者甲状腺功能异常发生率高,以ESS最常见,并且合并ESS的DM患者死亡率更高.DM伴发AITD不少见,最常见类型为HT.     

Therapeutic plasma exchange for control of thyroid storm

Therapeutic plasma exchange (TPE) for thyroid storm has recently been upgraded to a category II indication after decades though its recommendation level still remains at Grade 2C according to the American Society for Apheresis (ASFA). In the absence of prospective randomized controlled trials due to the rarity of thyroid storm, retrospective data from case series continue to elevate the clinical evidence supporting TPE as a life‐saving modality for complicated thyroid storm patients. We report three cases of life‐threatening thyroid storm from Graves' disease rescued by TPE via rapid reduction in circulating thyroid hormones. Each patient underwent TPE when it was judged that other thyroid storm treatment options were futile or unsafe. The first patient received 4 cycles of TPE while the second patient received 9 cycles of TPE, and the third patient received 2 cycles of TPE with satisfactory clinical improvement. Plasma FT4 and TSH receptor antibody levels of the first case declined by 41.3% and >50% respectively right after the first round of TPE; plasma FT4 of the second patient dropped by up to 31.6% during the course of TPE; plasma FT4 and TSH receptor antibody of the third patient declined by 66% and 56.2% respectively after the first cycle of TPE. This demonstrates the safety, efficacy, and feasibility of TPE in thyroid storm especially when other therapeutic interventions are contraindicated. TPE operates via the elimination of serum proteins‐bound thyroid hormones, thyroid autoantibodies, cytokines, and catecholamines in addition to increasing unsaturated binding sites for thyroid hormones.     

Postpartum thyroid dysfunction and HLA status

Nine-hundred-and-one women presenting in an antenatal clinic at the 60th week of pregnancy were tested for antithyroid antibodies. A group of 113 antibody-positive women and 108 antibody-negative age-matched controls were HLA typed and followed prospectively at 6-weekly intervals through pregnancy and for 12 months postpartum. Forty-five of the women developed biochemical evidence of postpartum thyroid dysfunction (PPTD) of whom 36 were antibody positive. Compared with a local control population (n = 600), and using multiplex analysis, there was a significant increase in the combinations HLA B8, DR3 and HLA A1, B8, DR3 from 22.5% to 40.0% (P less than 0.02) and from 18.6% to 35.6% (P less than 0.01) respectively in the women who developed PPTD. The well-recognized association of these haplotypes with other organ-specific autoimmune diseases provides further support for autoimmune events being implicated in the development of PPTD.     

Postpartum thyroid dysfunction and HLA status

Abstract. Nine-hundred-and-one women presenting in an antenatal clinic at the 60th week of pregnancy were tested for antithyroid antibodies. A group of 113 antibody-positive women and 108 antibody-negative age-matched controls were HLA typed and followed prospectively at 6-weekly intervals through pregnancy and for 12 months postpartum. Forty-five of the women developed biochemical evidence of postpartum thyroid dysfunction (PPTD) of whom 36 were antibody positive. Compared with a local control population ( n = 600), and using multiplex analysis, there was a significant increase in the combinations HLA B8, DR3 and HLA Al, B8, DR3 from 22.5% to 40.0% ( P <0.02) and from 18.6% to 35.6% ( P <0.01) respectively in the women who developed PPTD. The well-recognized association of these haplotypes with other organ-specific autoimmune diseases provides further support for autoimmune events being implicated in the development of PPTD.     

血脂异常患者甲状腺功能异常患病率的调查

目的 调查血脂异常患者甲状腺功能的变化特征,探讨血脂异常与甲状腺功能(TSH、FT3、FT4)相互间的关系.方法 调查412例血脂异常患者,男249例,女163例,平均年龄(50.7±15.7)岁,以497例无血脂异常的江苏省居民为对照,男287例,女210例,平均年龄(49.0±13.8)岁.比较两组人群甲状腺功能异常的患病率和其他指标.结果 血脂异常组有71例(17.2%)甲状腺功能异常,对照组有56例(11.3%),两组差异有显著性(P=0.001);女性、老年(≥50岁)及HDL-C降低均与血脂异常患者发生甲状腺功能异常相关.结论 血脂异常患者甲状腺功能异常患病率较正常人群高,需重视其甲状腺功能的常规检查.     

Serum cytokines and bone metabolism in patients with thyroid dysfunction

Hyperthyroidism is associated with increased bone turnover. Besides the hormones of calcium metabolism, locally produced factors are important in maintaining normal bone metabolism. Interleukin-6 (IL-6), in particular, has a major influence on bone turnover. In this study, serum IL-6 and tumor necrosis factor-alpha (TNF-α) levels, as well as bone turnover markers and relationships between them, were investigated in hyperthyroidism and hypothyroidism. A total of 20 female patients with hyperthyroidism, 15 with subclinical hyperthyroidism, 16 with hypothyroidism, and 15 with subclinical hypothyroidism constituted the patient groups. In all, 15 age-matched healthy female volunteers were recruited as controls. When compared with controls, serum TNF-a levels showed no significant difference in any of the patient groups (P<.05). In the groups with hyperthyroidism and subclinical hyperthyroidism, IL-6 levels were significantly higher compared with control group values (P< .05). Hyperthyroid patients showed higher levels of alkaline phosphatase (ALP) and osteocalcin, and a higher urinary deoxypyridinoline/creatinine ratio, compared with controls (P< .05). In subclinical hyperthyroidism, only ALP was found to be higher compared with control values. No significant correlations were made in any group between serum IL-6 or TNF-α level and bone turnover markers. Results suggest that serum IL-6 level and markers of bone turnover rate seem to be increased in hyperthyroidism. This finding may support the role of IL-6 in induction of bone turnover in hyperthyroid states.     

Diagnoses in opposition: thyroid storm and myxedema coma.

An overview of normal thyroid function is presented to facilitate the understanding of the pathophysiology of two life-threatening thyroid disorders: thyroid storm and myxedema coma. Signs and symptoms, medical management, nursing diagnoses and interventions, and expected patient outcomes are discussed, as is the important role of the nurse as an integral member of the management team.