Thyroid Storm and post-surgical hypoparathyroidism

Case discussion

Presenter: PGY Hsu Jin-YiSupervisor: VS Chen Hsiao-Lian

PATIENT

Mrs. Zhang

Age: 54 y/o

Past history: HTN for 4-5 years, DM under poor control, dyslipidemia, hyperthyroidism s/p subtotal thyroidectomy

BMI: 17.36 (BH: 145cm, BW: 36.5kg)

Chief complaint: Dyspnea with cold sweating for several hours.

• TSH receptor Ab: 52%• TSH: <0.015uIU/mL, free T4: 1.58ng/dL• PTU: 50mg QD10/09/09

• TSH receptor Ab: 52%• TSH: <0.015uIU/mL, free T4: 1.58ng/dL• PTU: 50mg QD10/09/09

• TSH: <0.015uIU/mL, free T4: 2.50 ng/dL• PTU: 75 mg BID

07/22/11

• TSH receptor Ab: 52%• TSH: <0.015uIU/mL, free T4: 1.58ng/dL• PTU: 50mg QD

• TSH: <0.015uIU/mL, T4: 7.18 ug/dL• PTU: 75 mg BID

10/09/09

02/16/12


07/22/11

• TSH receptor Ab: 52%• TSH: <0.015uIU/mL, free T4: 1.58ng/dL• PTU: 50mg QD

• TSH: <0.015uIU/mL, T4: 7.18 ug/dL• PTU: 75 mg BID

10/09/09

02/16/12


07/22/11

Loss follow-up

Before admission• Palpitation with chest tightness for few days.• Productive cough, rhinorrhea and sore throat for several

days.

Before admission• Palpitation with chest tightness for few days.• Productive cough, rhinorrhea and sore throat for several

days.

03/21/15

In ER• Vital sign: T: 36.2^C , P: 92 bpm , R: 22 bpm, BP: 192/99• Physical examination: no remarkable finding ( ER chart)• CBC: leukocytosis without left shift• BCS: Mild hyponatremia and hypokalemia• Troponin I: 47 ng/L• BNP: 651 pg/mL.• Free T4, TSH: pending• ECG & CXR

Af with RVR ( 157bpm)

Ischemia change over lat. wall.

3/21

Borderline cardiomegaly

Neither pulmonary edema nor active lesion

3/21

03/21/15

In ER• Troponin I: 106 ng/L ( ⬆ )

• ECG

Af with RVR ( 128 bpm)

Ischemia change over inf. and lat. wall.

3/21

3/21

Af with RVR ( 128 bpm)

Ischemia change over inf. and lat. wall.

Transferred to MICU

Suspected NSTEMI

3/21

GRACE score: 62, TIMI score: 2 Delayed invasive PTCG( within 25-72h)

03/22/15

In ICU• Leukocytosis evaluation: No obvious infection focus• PCT: 0.15 ng/L• ECG

03/21/15

In ER• Troponin I: 106 ng/L• ECG

Af with RVR ( 109 bpm)3/22

Ischemia change over inf., septal, and lat. wall.

Af with RVR ( 109 bpm)3/22

Plan: Diagnostic PTCG

Ischemia change over inf., septal, and lat. wall.

Neither pulmonary edema nor active lesion

3/23

Patent coronary artery

3/23

Apical balloning syndrome

Acute heart failure ( EF: 30%)

3/23

03/23/15

In ICU• Dyspnea, agitation after the procedure, suspected

choking• Emergent intubation and mechanical ventilation

03/23/15



Vital sign: T: 36.1^C , PR: 139 bpm , RR: 21, BP: 97/73

03/23/15



Vital sign: T: 36.1^C , PR: 139 bpm , RR: 21, BP: 97/73

• ID man: suspected aspiration pneumonia• Add Flumarin

03/23/15

• TSH: <0.015uIU/mL, free T4: >7.77 ng/dL, T3: 4.17ng/mL

03/23/15


• Meta man: suspected hyperthyroidism• Check TSH receptor Ab, PTU 50mg BID• If persistent stress: Hydrocortisone 100mg ST and 50mg

Q6H for one day, and taper steroid gradually.• Herbesser 15mg BID for rate control.• Follow-up Symptom and sign of thyroid storm as high

iodine contrast during PTCG

03/23/15


• Meta man: suspected hyperthyroidism• Check TSH receptor Ab, PTU 50mg BID• If persistent stress: Hydrocortisone 100mg ST and 50mg

Q6H for one day, and taper steroid gradually.• Herbesser 15mg BID for rate control.• Follow-up Symptom and sign of thyroid storm as high

iodine contrast during PTCG

Vital sign: T: 38^C , PR: 135 bpm , RR: 20, BP: 125/7903/23/15

03/23/15

• Rate control

• Carbedilol: 6.25mg BID

Diltiazem Bisoprolol Carvedilol

No pneumonia patch3/26

03/26/15

Seizure attack• Electrolyte: Ca: 4.4mg/dL, Mg: 1.5mg/dL• ABG: metabolic alkalosis• Brain CT: No ICH

03/26/15

Seizure attack• Electrolyte: Ca: 4.4mg/dL, Mg: 1.5mg/dL.• ABG: metabolic alkalosis• Brain CT: No ICH

• Calcium gluconate (IV), calcium bicarbonate (PO)

03/26/15

Seizure attack• Electrolyte: Ca: 4.4mg/dL, Mg: 1.5mg/dL.• ABG: metabolic alkalosis• Brain CT: No ICH

• Calcium gluconate (IV), calcium bicarbonate (PO)

03/27/15

• Electrolyte: Ca: 5.1mg/dL, P: 5.0 mg/dL.• iPTH: 3.26 pg/mL

• Vitamin D 0.25 ug BID

Calcium

4/3 Discontinue Calcium gluconate

Calcium

4/7 Consult nephrologist Titrated Vitamin D to 0.5 mcg BID

Final diagnosisGrave’s disease s/p subtotal thyroidectomy, without regular medication control, complicated with thyroid storm.

Post-surgical hypoparathyroidism

Apical ballooning syndrome, related to thyroid storm?

Seizure, related to thyroid storm?

Acute heart failure, EF: 30% ( remission now: EF: 54% 4/14 by heart echo)

discussion

Thyroid storm Post-surgical hypoparathyroidism

Journal of Intensive Care Medicine 2015, Vol. 30(3) 131-140

Thyrotoxicosis

Precipitating factor

Diagnostic criteria

Management

THYROID Volume 21, Number 6, 2011

Thyrotoxicosis

Grave’s disease

Thyroid-origin


Precipitating factorSurgery and

trauma-related

THYROID, Volume 22, Number 7, 2012


Poor compliance


Diagnostic criteria

4 plus 1


Diagnostic criteria

Multi-organ de-compensation


Diagnostic criteria

75


Diagnostic criteria

55


CNS manifestation plus 1

At least 3 combination

“Modified” diagnostic criteria


“Modified” diagnostic criteria

N Engl J Med 2005;352:905-17.

Management

N Engl J Med 2005;352:905-17.

Production

N Engl J Med 2005;352:905-17.

ProductionRelease

N Engl J Med 2005;352:905-17.

ProductionRelease

Activation


Management

Against production Against release Against activation


Management


Methimazole

PTU


Management


Methimazole

PTU Lugol’s solution

Sodium iodide

Lithium


Management


Methimazole

PTU Lugol’s solution Propranolol

Sodium iodide Hydrocortisone

Lithium PTU


Management


Management

10#-20# Loading, 5 # Q4H

3# Loading, 1 # Q8H

6#-12# Q4H-Q6H


ManagementBeta-blocker choice

Favor non-selective Beta-blocker

Block T4 to T3

N Engl J Med 2008;359:391-403

BMJ 2008;336:1298-302

PTH

Mg

Diagnosis

BMJ 2008;336:1298-302

Management

Calcium gluconate Vitamin D

PTH ⬇ PTH ✔

Endocr Pract. 2011;[Suppl 1]17:18-25

1#-2# IVD in 1-2 hours

1-3 mg/kg/h, maintain Ca> 8mg/dL

40% elemental calcium

21.1% elemental calcium

Calcium gluconate

Calcium bicarbonate

Calcium citrate

Back to our patient

Thyrotoxicosis


Diagnostic criteria

Management



Poor compliance


Diagnostic criteria

75


Management


Methimazole



Lithium PTU


Management


Methimazole



Lithium PTU

Carvedilol


Management


Methimazole



Lithium PTU

Carvedilol

Dosage?

Back to our patient


Diagnosis

Management

BMJ 2008;336:1298-302

PTH

Mg

Diagnosis

BMJ 2008;336:1298-302

Management


PTH ⬇

BMJ 2008;336:1298-302

Management


PTH ⬇

Dosage?

Thanks for your attention!

Thyroid Storm and post-surgical hypoparathyroidism

Health & Medicine

Transcript of Thyroid Storm and post-surgical hypoparathyroidism