Background: Thyroid storm is a rare complication of hyperthyroidism. It can lead to life-threatening complications such as Arrhythmias, multiorgan failure and disseminated intravascular coagulation (DIC) (1). In pregnant patients can cause spontaneous abortions, fetal demise (2). Aggressive treatment under critical care settings is needed. Clinical Case: We report a case of 24-year-old Indian female twelve weeks pregnant; background of Graves’ disease for five years, was on carbimazole but she discontinued since she became pregnant. Presented to Hamad general hospital with nausea, vomiting and altered mental status for one day. She was afebrile, normotensive, tachypneic, tachycardiac with heart rate of 150bpm, and confused. Investigations showed supraventricular tachycardia aborted by adenosine and amiodarone, TSH was < 0.01mIU/l(0.3-4.2) and FT4> 100 pmol/L(11.6-21.9),normal baseline liver function and complete blood counts. In the emergency department, she was managed for thyroid storm with hydrocortisone, propranolol, propylthiouracil (PTU), iodine solution and cholestyramine. Then suddenly she deteriorated requiring intubation and vasopressor support under care of Medical Intensive Care Unit (MICU) progressed to multiorgan failure; acute liver injury, acute kidney injury and DIC. So, PTU was stopped and started on plasma exchange followed by total thyroidectomy and tracheostomy. US pelvis showed nonviable fetus, so dilation and curettage were done by obstetric team. Afterwards, she markedly improved except her conscious level and kidney function which required Hemodialysis. MRI brain showed small subdural hematoma treated conservatively and Wernicke encephalopathy treated with thiamine with substantial response and spontaneously breathing. Post thyroidectomy she required calcium supplementation and levothyroxine, liver function and coagulation parameters back to baseline. Conclusion: Thyroid storm in pregnancy is a medical emergency with high mortality rate, it needs high index of suspicion and early aggressive management by a multidisciplinary team. Plasmapheresis may be considered for challenging cases as a bridge for definitive therapy. Thyroidectomy may be the only option in selected cases like our case. References: 1. Karger S, Führer D. Thyreotoxische Krise--ein Update [Thyroid storm--thyrotoxic crisis: an update]. Dtsch Med Wochenschr. 2008 Mar;133(10):479-84. German. doi: 10.1055/s-2008-1046737. PMID: 18302101. 2. Ma Y, Li H, Liu J, Lin X, Liu H. Impending thyroid storm in a pregnant woman with undiagnosed hyperthyroidism: A case report and literature review. Medicine (Baltimore). 2018;97(3):e9606. doi:10.1097/MD.0000000000009606
Background: Hypopituitarism refers to complete or partial insufficiency of pituitary hormone secretion and patients require lifelong hormone replacement. Those with ACTH deficiency rely on exogenous glucocorticoids and at times of intercurrent illness require stress doses to prevent an adrenal crisis. The benefits and adverse effects of corticosteroids for treatment of COVID-19 pneumonia are currently under investigation. We report our experience in a patient with COVID-19 pneumonia who received high dose corticosteroids for panhypopituitarism. Clinical Case: A 51-year-old man presented with one-week history of fever and generalized weakness. He had been diagnosed with a non-functional pituitary macro-adenoma causing panhypopituitarism 1 year ago when he developed generalized tonic-clonic seizures. He underwent trans-sphenoidal resection of the pituitary adenoma. However, he then discontinued his hormonal therapy and was lost to follow up. He had postural hypotension but was not tachypneic or hypoxemic. He tested positive for COVID-19 and chest x-ray showed prominent bilateral broncho-vascular markings; he was hospitalized as mild COVID-19 pneumonia. Laboratory investigations revealed secondary adrenal insufficiency, secondary hypothyroidism and hypogonadotropic hypogonadism. MRI of the pituitary now showed persistence of the pituitary macroadenoma, measuring 3.5 x 3.7 x 2.4 cm in dimensions, causing sellar obliteration and left cavernous sinus invasion. Treatment with stress dose steroids, Hydrocortisone 50 mg 4 times daily was initiated, followed by thyroid hormone replacement with Levothyroxine 125 mcg daily. He also received antivirals and supportive care for COVID-19, guided by local hospital protocol. After significant clinical improvement, steroids were tapered down and he was discharged on a maintenance dose of 20 mg hydrocortisone per day in divided doses. The patient was stable at outpatient follow up after one month. He was started on testosterone replacement for erectile dysfunction due to hypogonadotropic hypogonadism. He was offered surgery for complete resection of the residual pituitary adenoma, but he declined and preferred to continue medical therapy. Conclusion: Hypopituitarism is associated with significant morbidity and premature mortality, a key risk factor being cortisol deficiency. Adrenal crisis is a life-threatening medical emergency and remains an important cause of death in patients with adrenal insufficiency. These patients are also vulnerable to develop severe complications from COVID-19 infection due to the absence of normal cortisol responses to stress. Despite receiving stress dose corticosteroids, this high-risk patient recovered from COVID-19 pneumonia without complications. These findings support the use of corticosteroids when necessary for treatment of coexisting conditions in patients with COVID-19.
Background: The Coronavirus disease 2019 (COVID-19) pandemic impacted health care systems in all countries, including Qatar. Hamad Medical Corporation (HMC); In compliance with recommendations, suspended all non-urgent procedures, including thyroid fine needle aspiration biopsies (FNAB). Thyroid nodules are second most common cause of referral to HMC endocrine clinic. FNABs are gold standard to differentiate benign from malignant nodules.1- 2 Methods: Our approach includes a teleconsultation to obtain patient’s history and risk factors. Reviewing neck ultrasound (US), obtaining a calcitonin level if indicated, considering comorbidities associated with a high risk of COVID-19 morbidity and mortality.3 Results: We developed a pathway triaging thyroid (FNAB) to:1-Urgent: patients at higher risk of aggressive thyroid malignancy. Benefits of early detection and treatment outweigh the risk of COVID-19 exposure.4 FNAB should not be delayed.2-Semi-urgent: patients at low risk for COVID-19 and high suspicion thyroid nodules, but no evidence that early detection improves survival2, FNAB may be delayed up to 12 months.3-Non-urgent: patients with asymptomatic nodules that have low or intermediate suspicion US pattern.2 Also, includes nodules with ATA high suspicion US pattern in pregnant women and patients at high risk for COVID-19. The risks outweigh the benefits. FNAB should be delayed until outbreak is controlled.4 When urgent FNAB is indicated, safety of patients and medical staff needs to be addressed.5 We recommend testing patient for COVID-19 before FNAB, utilizing US guidance with rapid on-site adequacy evaluation in all cases. Cervical lymph node FNAB with TG washout should be done if indicated. The patient should wear a mask. All medical staff involved should wear personal protective equipment (PPE). The operator should wear N95 mask and face shield. The patient should be informed about cytopathology results via telemedicine. Conclusion: Triaging thyroid (FNAB) during the COVID-19 pandemic should be based on nodule characteristics and risk of COVID-19 morbidity and mortality. Our group recommends deferring FNAB for asymptomatic patients.4FNAB should not be delayed in selected patients who benefit from early detection and intervention. Table1: Triage of Thyroid fine needle aspiration biopsies (FNAB). ATA: American thyroid association. US: ultrasound.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.