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Diagnosis and Treatment > Medication

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Tomomi Nakao First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Ken Takeshima First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Hiroyuki Ariyasu First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Chiaki Kurimoto First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Shinsuke Uraki First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Shuhei Morita First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Yasushi Furukawa First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Hiroshi Iwakura First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Takashi Akamizu First Department of Internal Medicine, Wakayama Medical University, Wakayama City, Wakayama, Japan

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Summary

Thyroid storm (TS) is a life-threatening condition that may suffer thyrotoxic patients. Therapeutic plasma exchange (TPE) is a rescue approach for TS with acute hepatic failure, but it should be initiated with careful considerations. We present a 55-year-old male patient with untreated Graves’ disease who developed TS. Severe hyperthyroidism and refractory atrial fibrillation with congestive heart failure aggregated to multiple organ failure. The patient was recovered by intensive multimodal therapy, but we had difficulty in introducing TPE treatment considering the risk of exacerbation of congestive heart failure due to plasma volume overload. In addition, serum total bilirubin level was not elevated in the early phase to the level of indication for TPE. The clinical course of this patient instructed delayed elevation of bilirubin until the level of indication for TPE in some patients and also demonstrated the risk of exacerbation of congestive heart failure by TPE.

Learning points:

  • Our patient with thyroid storm could be diagnosed and treated promptly using Japan Thyroid Association guidelines for thyroid storm.

  • Delayed elevation of serum bilirubin levels could make the decision of introducing therapeutic plasma exchange difficult in cases of thyroid storm with acute hepatic failure.

  • The risk of worsening congestive heart failure should be considered carefully when performing therapeutic plasma exchange.

Taxonomy:
Clinical Overview, Gland/Organ, Heart, Kidney, Thyroid, Topic, Thyroid, Hormone, Thyroxine (T4), Triiodothyronine (T3), TSH, Condition/ Syndrome, Graves' disease, Hyperthyroidism, Thyroid storm, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Japan, Diagnosis and Treatment, Signs and Symptoms, Atrial fibrillation, Conjunctivitis, Coughing, Diarrhoea, Dyspnoea, Eyelid swelling, Fatigue, Goitre, Heart failure, Hyperthyroidism, Oedema, Oliguria, Proptosis, Pyrexia, Tachycardia, Thyrotoxicosis, Tremulousness, Weight loss, Investigation, Alanine aminotransferase, Albumin, Alkaline phosphatase, Bilirubin, Blood pressure, Brain natriuretic peptide, Chloride, Creatinine (serum), Electrocardiogram, FT3, FT4, Lactate dehydrogenase, Platelet count, Potassium, Red blood cell count, Sodium, Thyroid antibodies, TSH, Ultrasound scan, Urea and electrolytes, Urinalysis, White blood cell count, X-ray, Intervention, Dialysis, Thyroidectomy, Medication, Beta-blockers, Glucocorticoids, Hydrocortisone, Levothyroxine, Methimazole, Norepinephrine, Potassium iodide, Publication Details, Case Report Type, Insight into disease pathogenesis or mechanism of therapy
DOI:
https://doi.org/10.1530/EDM-20-0036
Volume/Issue:
Volume 2020: Issue 1
Open access
Luísa Correia Martins Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Ana Rita Coutinho Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Mónica Jerónimo Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Joana Serra Caetano Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Rita Cardoso Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Isabel Dinis Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Alice Mirante Department of Pediatric Endocrinology, Diabetes and Growth, Pediatric Unit, Coimbra Hospital and Universitary Center, Coimbra, 3030, Portugal

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Summary

Alternating between hyper- and hypo-thyroidism may be explained by the simultaneous presence of both types of TSH receptor autoantibodies (TRAbs) – thyroid stimulating autoantibodies (TSAbs) and TSH blocking autoantibodies (TBAbs). It is a very rare condition, particulary in the pediatric age. The clinical state of these patients is determined by the balance between TSAbs and TBAbs and can change over time. Many mechanisms may be involved in fluctuating thyroid function: hormonal supplementation, antithyroid drugs and levels of TSAbs and TBAbs. Frequent dose adjustments are needed in order to achieve euthyroidism. A definitive therapy may be necessary to avoid switches in thyroid function and frequent need of therapeutic changes. We describe an immune-mediated case of oscillating thyroid function in a 13-year-old adolescent. After a short period of levothyroxine treatment, the patient switched to a hyperthyroid state that was only controlled by adding an antithyroid drug.

Learning points

  • Autoimmune alternating hypo- and hyper-thyroidism is a highly uncommon condition in the pediatric age.

  • It may be due to the simultaneous presence of both TSAbs and TBAbs, whose activity may be estimated in vitro through bioassays.

  • The clinical state of these patients is determined by the balance between TSAbs and TBAbs and can change over time.

  • The management of this condition is challenging, and three therapeutic options could be considered: I-131 ablation, thyroidectomy or pharmacological treatment (single or double therapy).

  • Therapeutic decisions should be taken according to clinical manifestations and thyroid function tests, independent of the bioassays results.

  • A definitive treatment might be considered due to the frequent switches in thyroid function and the need for close monitoring of pharmacological treatment. A definitive treatment might be considered due to the frequent switches in thyroid function and the need for close monitoring of pharmacological treatment.

Taxonomy:
Clinical Overview, Gland/Organ, Thyroid, Topic, Thyroid, Hormone, TSH, Condition/ Syndrome, Autoimmune disorders, Hyperthyroidism, Hypothyroidism, Thyroiditis, Patient Demographics, Age, Adolescent/young adult, Gender, Female, Ethnicity, White, Country of Treatment, Portugal, Diagnosis and Treatment, Signs and Symptoms, Goitre, Hyperthyroidism, Hypothyroidism, Investigation, FT4, Thyroid antibodies, Thyroid function, Thyroid scintigraphy, Total T3, Total T4, TSH, Ultrasound scan, Medication, Levothyroxine, Methimazole, Related Disciplines, Paediatrics, Publication Details, Case Report Type, Insight into disease pathogenesis or mechanism of therapy
DOI:
https://doi.org/10.1530/EDM-15-0131
Volume/Issue:
Volume 2016: Issue 1
Open access