Thyroid stormพญ.อนตตร ดาวราย

หนวยโรคตอมไรทอ

PP: ผปวยชายไทยคอาย 26 ป อาชพท าไร ภมล าเนา จ.นครราชสมา

CC: ไข ถายเหลวมา 7 วนกอนมารพ.

PI: 5 เดอนกอนมารพ.รสกเหนอยงาย ใจสนบอยๆ มอสน กนเกงขน เหงอออกมากกวาปกต นน.ลดลง 8 กก.ใน ชวง 5 เดอนน มคนทกวาคอโตขนแตไมไดไปพบแพทย

• 7 วนกอนมารพ. มไข ถายเหลวเปนน าปนเนอไมมมกเลอดปน วนละ 4-5 ครงๆละ 1 แกวทกวน มคลนไสอาเจยนวนละ 3 ครงๆละ 1 แกว เหนอยเพลยมาก รสกใจสนมากขนกวาเดม ตอนกลางคนตองนอน หนนหมอนสงๆ หลายๆใบ นอนราบแลวรสกอดอดตองลกขนนงบอยๆ มขาบวมขน 2 ขาง ญาตสงเกตวาผปวยดกระสบกระสาย อาการไมดจงพามารพ.

PH: ปฎเสธโรคประจ าตว ไมไดกนยาอะไรประจ า ไมเคยเจบปวยตองนอนรพ.มากอน ไมเคยผาตด ไมเคยแพยา แพอาหาร ไมเคยกนยาตม ยาหมอ ยาลกกลอน ยาสมนไพร ไมเคยใชสารเสพยตด ไมมอาการเจบทคอมากอน

Personal Hx: ไมสบบหร ดมเหลาตามงานสงสรรคFH: มลกชาย 1 คนแขงแรงด ปฎเสธประวตโรคไทรอยดในครอบครว

PE: V/S: BP 128/80 mmHg.,PR 120/min, RR 20/min, T 39˚CGA: A Thai man, good consciousness, look agitatedHEENT: not pale, anicteric sclera,

exophthalmos of both eyes,lid lag and lid retraction – present

JVP: engorgedThyroid gl: diffuse enlarged 45 gm,

soft consistency, smooth surface, not tender, bruit – present

Lymph node: can’t palpable Heart: apex at 5th ICS MCL, no heave, no thrill,

totally irregular HR 120/min, normal S1 S2,no murmur

Lungs: fine crepitation both lungsAbd: soft, not tender, liver – 2 FB below RCM,

liver span 15 cm., spleen – not palpable

Ext: warm and moist skin, fine tremor – present,no clubbing finger, pitting edema 2+ both legs, no pretibial myxedema

Neuro: agitated, good consciousness, other- WNL

Problem list

1. Fever with diarrhea and vomiting

2. Congestive heart failure

3. AF with RVR

4. R/O Thyrotoxicosis

Thyroid storm

CBC: Hb 12 g/dL, Hct 36%, WBC 9,800 /µL(N 72%, L 21%),

Plt 230,000/µL

TFT: FT3 15.6 pg/mL (normal 2.3-6.9 pg/mL),

FT4 4.8 ng/dL (normal 0.6-1.6 ng/dL),

TSH 0.021 mIU/L (normal 0.3-5.0 mIU/L)

BUN 20 mg/dL, Cr 1.2 mg/dL

Electrolyte: Na 138 mEq/L, K 4.2 mEq/L,

Cl 102 mEq/L, C02 22 mEq/L

Lab

Burch-Wartofsky-Score

1. Thermoregulatory dysfunction

Temperature ˚F (˚C) Scoring points

99–99.9 (37.2-37.7) 5

100–100.9 (37.8-38.2) 10

101–101.9 (38.3-38.8) 15

102–102.9 (38.9-39.2) 20

103–103.9 (39.3-39.9) 25

>/= 104.0 (>/= 40.0) 30

2. Central nervous system effects

Burch-Wartofsky-Score

Scoring points

Absent 0

Mild (agitation) 10

Moderate (delirium, psychosis, extreme lethargy

20

Severe (seizures, coma) 30

3. Gastrointestinal-hepatic dysfunction

Burch-Wartofsky-Score

Scoring points

Absent 0

Moderate (diarrhea, nausea/vomiting, abdominal pain)

10

Severe (unexplained jaundice) 20

Burch-Wartofsky-Score

4. Cardiovascular dysfunction

Scoring points

Tachycardia (beats/minute)

90–109 5

110–119 10

120–129 15

≥ 140 25

Burch-Wartofsky-Score

4. Cardiovascular dysfunctionScoring points

Congestive heart failure

Absent 0

Mild (pedal edema) 5

Moderate (bibasilar rales) 10

Severe (pulmonary edema) 15

Atrial fibrillation

Absent 0

Present 10

5. Precipitating cause

Burch-Wartofsky-Score

Scoring points

Absent 0

Present 10

Scoring system

≥ 45 highly suggestive of thyroid storm

25-44 suggestive of impending storm

< 25 unlikely to represent thyroid storm

This patient’s score was 90

Treatment

1.Specific treatment

2.Supportive treatment

3.Treatment of precipitating cause

4.Definitive treatment

Specific treatment

Principles

Inhibition of new thyroid hormone production

Inhibition of thyroid hormone release

Inhibition of peripheral conversion

Inhibition of new thyroid hormone production

• PTU 200-250 mg po q 4 hr or

• MMI 20 mg po q 4 hr

Inhibition of thyroid hormone release

• Lugol’s solution 10 drops PO q 8 hr or

• SSKI 3 drops PO q 8 hr

Start after an antithyroid drug 1-2 hr

duration : 1 week

Iodine content Lugol’s solution :

6-8 mg/dropSSKI : 38 mg/drop

Inhibition of peripheral conversion

• Dexamethasone 2 mg IV q 6 hr

duration : 3-4 days

Fever - antipyretic drug

• Acetaminophen is a preferable choice

• Salicylates should be avoided

IV fluid - IV fluids with dextrose (isotonic

saline with 5% or 10% dextrose)

Beta blockers

Supportive treatment

• Discontinuation of an antithyroid drug

• Surgery

• Trauma

• Severe infection

• Excessive ingestion or IV administration

of iodine (e.g., radiocontrast agents,

amiodarone, radioiodine therapy)

• High dose of thyroid hormone

Precipitating factors

• Subtotal thyroidectomy

• Radioactive iodine ablation

Definitive treatment

Adrenal insufficiency

Anuttree Daorai,M.D.

Causes of Adrenal InsufficiencyPrimary

Acute Onset• Adrenal Hemorrhage

or Infarction

Slow Onset• Autoimmune Disease

- Adrenalitis

• Infectious Diseases

- Tuberculosis

- AIDS-Related

• Cancer

- Lymphoma

- Metastases

• Drugs

- Ketoconazole

- Etomidate

• Other

- CAH

-Adrenoleukodystrophy

Causes of Adrenal InsufficiencySecondaryAcute Onset

• Pituitary Apoplexy• Pituitary/hypothalamic

Surgery• Traumatic Brain InjurySlow Onset

• Autoimmune Disease - Lymphocytic

hypophysitis• Infectious Disease - Tuberculosis• Cancer - Pituitary tumors - Lymphoma

• Trauma or Other Injury - Traumatic Brain Injury - Subarachnoid

Hemorrhage - Radiation• Drugs - Megestrol Acetate

Causes of Adrenal InsufficiencySecondarySlow Onset

• Other - Discontinuation of exogenous glucocorticoids - Sarcoidosis - Empty Sella Syndrome

Clinical manifestation

Primary & Secondary AI

• Tiredness, mental depression, anorexia,

weight loss, fever

• Orthostatic hypotension

• Hypotension from hypomineralocorticoid

• Hyponatremia, normal gap met.acidosis,

hypoglycemia ,mild normocytic anemia,

lymphocytosis, eosinophilia, hypercalcemia

Clinical manifestation 10 vs. 20

Primary

• Hyperpigmentation

• Hyperkalemia

• Vitiligo,autoimmune

disorder

• CNS

adrenomyeloneuropathy

Secondary

• Pale skin without

marked anemia

• Other pituitary

hormone def.

Investigation1. Screening

• Early morning basal serum cortisol

- < 3 ug/dl, >18ug/dl

• Plasma ACTH

2. Stimulation test

• Insulin induced hypoglycemia

- RI 0.1 unit/kg iv

- 0, 30, 60, 90 min for cortisol, ACTH

• 250 ug ACTH(serum cortisol >18-20 ug/dl)

• 1 ug ACTH

• Glucocorticoid replacement

- Prednisolone 5 mg(2.5-7.5) OD

- Stress; Increase dose(2-3 times)

• Mineralocorticoid replacement in 1o AI

- Fludrocortisone 0.1mg(0.05-0.2) OD

- unnecessary if hydrocortisone > 100 mg/d

Treatment

• Dose (need to know previous

dosage, not only current dosage)

• Duration

• Dexamethasone > prednisolone >

hydrocortisone

• Also inhale, topical form

HPA axis suppression

Assumed to have HPA suppression

• Prednisolone(or equivalence) >20 mg/d > 3 wks

• Clinical Cushing’s syndrome from any steroid

dose

• Any patient who has received any

dose of glucocorticoid for < 3 weeks

• Patients who have received morning

doses of < 5 mg/day of prednisone

or its equivalent

• Patients treated with alternate-day

glucocorticoid therapy

No HPA suppression

• > 5 - < 20 mg/dl for > 3 weeks, one

can test for adrenal insufficiency or

give stress dose of glucocorticoid

Gray zone

Med Clin North Am 2001;85(5):1311-7

• In general, adrenal gland produces about

- normal basal secretion is 8 – 10 mg/d

- minor procedure or surgery : 50 mg/d

- major stress: 75 – 100 mg/d

Cortisol secretion during stress

Commonly used GCs

Guidelines for adrenal supplementation therapy

JAMA 2002;287(2):236-40

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