Thyroid storm as an early presentation of hCG-producing metastatic choriocarcinoma: a case report and review of the literature

Human chorionic gonadotropin (hCG)-induced hyperthyroidism has been previously reported as a rare paraneoplastic syndrome in non-seminomatous germ cell tumours and usually presents with mild symptoms or subclinical thyrotoxicosis. We present a case of a young adult man who consulted with abdominal pain, nausea and emesis. On admission, he was found to be tachycardic, febrile, anxious and with icteric sclera and tenderness to palpation in the right upper abdomen. A right scrotal mass was also noted. Initial studies revealed transaminitis, hyperbilirubinaemia, suppressed thyroid-stimulating hormone and elevated free T4. Scrotal biopsy confirmed diagnosis of testicular choriocarcinoma with an elevated hCG level of 6074 mIU/mL, which was corrected to 6 760 713 mIU/mL when reassessed with dilution. The clinical scenario reflected hCG-induced thyrotoxicosis concerning for thyroid storm. Euthyroid state was restored after initiation of chemotherapy and a short course of methimazole. Unfortunately, the patient passed away due to progression of his malignant disease. This case suggests that when choriocarcinoma is suspected, the use of iodinated contrast agents should be limited to avoid precipitation of thyroid storm or worsening of hCG-induced hyperthyroidism. Moreover, if the clinical picture does not support a primary aetiology of hyperthyroidism and hCG is not concordantly elevated, reassessment of hCG by dilution should be considered as hCG assays are subject to prozone effect.

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(P2-60) Thyroid Storm in the Emergency Department

Prehospital and Disaster Medicine ◽

10.1017/s1049023x11005048 ◽

2011 ◽

Vol 26 (S1) ◽

pp. s155-s155

Author(s):

M.J. Van veelen ◽

L. Yurtsever ◽

M. Baggen ◽

E.A. Dubois

Keyword(s):

Emergency Department ◽

Urine Analysis ◽

Heart Rhythm ◽

Adult Mortality ◽

Thyroid Stimulating Hormone ◽

Thyroid Storm ◽

Beta Blockade ◽

Life Threatening ◽

The Right ◽

Cardiac Care Unit

CaseA 20-year-old woman was referred to the emergency department with rapid acceleration of complaints of palpitations, fever, diarrhea, and agitation that had been present for several weeks. During physical examination, the patient was uncomfortable and restless with a tachycardia of 170/minute, and a fever of 38.5 °C. Palpation of the neck revealed a small ventral, painless, solid elastic mass, more prominent on the right side, clinically suspicious for goiter. An electrocardiograph showed an atrial flutter of 150/min. Initial laboratory results showed an erythrocyte sedimentation rate of 35 mm/hour (0–20 mm/hour) and urine analysis tested positive for ketones.Outcome and TreatmentThe patient was presumed to be suffering from a thyroid storm. She was treated promptly with Propranolol 160 mg and Thiamazole 30 mg twice daily at the emergency department. She was admitted to the Cardiac Care Unit for observation of the heart rhythm, which slowed down to 110/minute the same day and her condition improved clinically. The following day her laboratory result confirmed the diagnosis with a thyroid-stimulating hormone of < 0.01 mIU/L (0.4–4.0 mIU/L) and a free thyroxine (T4) of > 75 pmol/l (10–22 pmol/l). Eventually, she was diagnosed with Graves Disease.DiscussionThyroid storm is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones. The adult mortality rate is high (90%) if early diagnosis is not made and the patient is left untreated. Therefore, in case of clinical suspicion for thyroid storm, it is critical to start prompt treatment with Beta blockade and Thiamazole before the diagnosis can be confirmed biochemically.

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Prevalence of thyroid dysfunction and effect of contrast medium on thyroid metabolism in cardiac patients undergoing coronary angiography

Acta Radiologica ◽

10.1258/ar.2012.120326 ◽

2013 ◽

Vol 54 (1) ◽

pp. 42-47 ◽

Cited By ~ 12

Author(s):

Paolo Marraccini ◽

Massimiliano Bianchi ◽

Antonio Bottoni ◽

Alessandro Mazzarisi ◽

Michele Coceani ◽

...

Keyword(s):

Coronary Angiography ◽

Contrast Medium ◽

Thyroid Function ◽

Thyroid Dysfunction ◽

Thyroid Stimulating Hormone ◽

Low T3 Syndrome ◽

Free T4 ◽

Free T3 ◽

Iodinated Contrast ◽

Low T3

Background Iodinated contrast media (CM) may influence thyroid function. Precautions are generally taken in patients with hyperthyroidism, even if subclinical, whereas the risks in patients with hypothyroidism or low triiodothyronine (T3) syndrome are not considered as appreciable. Purpose To assess the presence and type of thyroid dysfunction in patients admitted for coronary angiography (CA), to assess the concentration of free-iodide in five non-ionic CM, and to evaluate changes in thyroid function after CA in patients with low T3 syndrome. Material and Methods We measured free T3, free thyroxine (T4), and thyroid-stimulating hormone (TSH) in 1752 consecutive patients prior to CA and free-iodide in five non-ionic CM. Urinary free-iodide before and 24 h after CA, and thyroid hormone profile 48 h after CA were also made in 17 patients with low T3 syndrome. Patients were followed up for an average duration of 63.5 months. Results The patients were divided into four groups: euthyroidism (60%), low T3 syndrome (28%), hypothyroidism (10%), and hyperthyroidism (2%). The free-iodide resulted far below the recommended limit of 50 μg/mL in all tested CM. In low T3 syndrome, 24-h free-iodide increased after CA from 99.9± 63 ug to 12276±9285 ug (P< 0.0001). A reduction in TSH (4.97±1.1 vs. 4.17±1.1 mUI/mL, P < 0.01) and free T3 (1.44±0.2 vs. 1.25±0.3 pg/mL, P < 0.01), with an increase in free T4 (11.3±2.9 vs. 12.5±3.4 pg/dL, P < 0.001), was found. Patients with functional thyroid disease in the follow-up had a significant lower rate survival compared to euthyroid patients (90.7 vs. 82.2%, P < 0.00001). Conclusion Thyroid dysfunction is frequent in patients who perform a CA, and low T3 syndrome is the predominant feature. The administration of contrast medium may further compromise the thyroid function.

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Effect of Contrast Media used in Coronary Angiography on Thyroid Function

International Journal of Scientific Research in Science and Technology ◽

10.32628/ijsrst196468 ◽

2019 ◽

pp. 339-344

Author(s):

Khaled S. El-Hadidy ◽

Rania E. Sheir ◽

M.N. Salem ◽

Ahmed M. EL-Dien ◽

Yasser A. Abd El-Hady

Keyword(s):

Coronary Angiography ◽

Contrast Media ◽

Thyroid Function ◽

Subclinical Hypothyroidism ◽

Thyroid Dysfunction ◽

Thyroid Stimulating Hormone ◽

P Value ◽

Free T4 ◽

Iodinated Contrast ◽

Significant Difference

Radiocontrast-induced thyroid dysfunction prevalence has not been assessed accurately. It is greater among patients with pre-existing thyroid disease. Aim of this work to investigate effect of iodinated radiographic contrast media used in coronary angiography on the thyroid function in euthyroid patients. This study was conducted on 85 patients underwent elective coronary angiography. Baseline assessment of Free Thyroxine (FT4) and Thyroid-stimulating hormone (TSH) for the patients and three months later after Coronary Angiography. We observed that there was a statistically significant increase of TSH levels from baseline till 3 months following administration of contrast media (P-value=0.007). However, there was no statistical significant difference of Free T4 level from baseline till 3 (P-value=0.765). The incidence of increased TSH above normal range was 2.4% after 3 months ( 2 subclinical hypothyroidism cases). We noticed that there were no effect of age, gender, hypertension, diabetes, type of contrast, creatinine level or GFR on increased the level of TSH above normal value after 3 months. So, administration of Iodinated Contrast Media (ICM) associated with thyroid dysfunction mainly subclinical hypothyroidism so we should closely monitor patients after receiving ICM especially who have thyroid dysfunction.

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Lugol's solution-induced painless thyroiditis

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-17-0034 ◽

2017 ◽

Vol 2017 ◽

Cited By ~ 1

Author(s):

Ji Wei Yang ◽

Jacques How

Keyword(s):

Thyroid Stimulating Hormone ◽

Thyroid Storm ◽

Graves Disease ◽

List Type ◽

Free T4 ◽

Iodine Excess ◽

Thyroid Glands ◽

Painless Thyroiditis ◽

Learning Points ◽

Painful Thyroiditis

Summary Lugol’s solution is usually employed for a limited period for thyroidectomy preparation in patients with Graves’ disease and for the control of severe thyrotoxicosis and thyroid storm. We describe a rare case of Lugol’s solution-induced painless thyroiditis. In November 2014, a 59-year-old woman was prescribed Lugol’s solution four drops per day for the alleviation of menopausal symptoms. She was referred to our clinic in June 2015 for fatigue, hair loss, and a 20-lb weight loss without thyroid pain or discomfort. Physical examination revealed a normal thyroid gland. On 7 May 2015, laboratory tests revealed a suppressed thyroid-stimulating hormone (TSH) 0.01 U/L with elevated free T4 3.31 ng/dL (42.54 pmol/L). Repeat testing on 25 May 2015 showed spontaneous normalization of the free thyroid hormone levels with persistently low TSH 0.10 U/L. Following these results, a family physician prescribed methimazole 10 mg PO TID and very soon after, the TSH concentration rose to >100 U/L along with subnormal free T4 and T3 levels. Methimazole was promptly discontinued, namely within 18 days of its initiation. Over the course of the next few months, the patient spontaneously achieved clinical and biochemical euthyroidism. To our knowledge, this is a unique case of painless thyroiditis induced by Lugol’s solution, which has not been reported before. Lugol’s solution is a short-term medication given for the preparation of thyroidectomy in patients with Graves’ disease and for the control of severe thyrotoxicosis. Iodine excess can cause both hyperthyroidism and hypothyroidism. Rarely, Lugol’s solution can cause acute painless thyroiditis. Learning points: Lugol’s solution is used for thyroidectomy preparation in patients with Graves’ disease and for the control of severe thyrotoxicosis and thyroid storm. Iodine excess can cause both hypothyroidism and thyrotoxicosis. Thyroid glands with an underlying pathology are particularly susceptible to the adverse effect of iodine. The prolonged off-label use of Lugol’s solution can be harmful. Rarely, Lugol’s solution can cause acute painful thyroiditis.

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Management of Atrial Flutter in Thyroid Storm

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1923 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A941-A941

Author(s):

Theresa N Lanham ◽

Farah Hena Morgan

Keyword(s):

Atrial Flutter ◽

Hot Flashes ◽

Gastrointestinal Symptoms ◽

Liver Function Tests ◽

Thyroid Stimulating Hormone ◽

Thyroid Storm ◽

Beta Blockade ◽

Free T4 ◽

Free T3 ◽

History Of

Abstract Introduction: Thyroid storm, life-threatening hyperthyroidism, commonly presents with tachyarrhythmias. We present a case of hyperthyroid-induced atrial flutter, refractory to beta-blockade, successfully treated with electrical cardioversion (CV) while biochemically hyperthyroid. Case Description: A 49-year-old female with history of asthma and no family or personal history of thyroid disease presented with new-onset atrial flutter and heart failure. The patient endorsed weight loss, hot flashes, anxiousness, tremors, and palpitations. She denied gastrointestinal symptoms or visual changes. She was afebrile with normal mentation. Heart rate was found to be 260 beats per minute (bpm) in atrial flutter. Exam demonstrated bilateral lower extremity edema, and profound exophthalmos. Labs were remarkable for thyroid stimulating hormone (TSH) <0.01 [ref: 0.27-4.2] uIU/mL, free T4 4.5 [ref: 0.8-1.8] ng/dL, free T3 15.5 [ref: 2.0-4.4] pg/mL, thyroid stimulating immunoglobulin (TSI) of 379 [ref: <140] % and a thyroid receptor antibody (TRab) of 10.02 [ref:<=2.0] IU/L. White blood cell count and liver function tests were normal. Chest x-ray (CXR) showed bilateral pulmonary edema and ultrasound showed an enlarged heterogeneous hypervascular thyroid gland. The patient was initially started on Methimazole 30 mg daily and Metoprolol 25 mg every six hours but on day two, the patient was transitioned to Propylthiouracil (PTU) 250 mg every 6 hours given continued atrial flutter and concern for thyroid storm given Burch-Wartofsky score was 50. She was also given potassium iodide for three days. Cardioversion was deferred, as it was felt that the severity of thyrotoxicosis would limit success. On day six, TFTs were improved with a free T4 of 2.2, free T3 3.6. On day 8, because of continued tachycardia >130 bpm with limitation of beta-blockade due to hypotension, she underwent a cardioversion which was successful. On discharge, free T4 was 1.7 and she was transitioned to Methimazole 40 mg daily. Discussion: Thyroid storm has a mortality rate of 10-20%, often related to tachyarrhythmias which can be difficult to treat during a hyperthyroid state. Tachycardia should initially be treated with beta-blockade and antithyroid therapy. Amiodarone is avoided due to concern for worsening hyperthyroidism. A literature review suggests that electrical CV should not be attempted until a patient is euthyroid for four months, as a majority will spontaneously revert once thyroid levels normalize. Conversely, other studies have found that the rate of recurrence of atrial fibrillation between clinically hyperthyroid and euthyroid patients was not statistically significant, suggesting CV should not be delayed until a patient is euthyroid. This suggests that further studies need to be completed to better elucidate appropriate timing in hyperthyroid patient’s refractory to pharmacologic treatment alone.

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Multiple endocrinopathies, hypercalcaemia and pancreatitis following combined immune checkpoint inhibitor use- case report and review of literature

BMC Endocrine Disorders ◽

10.1186/s12902-021-00693-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Christine Newman ◽

Oratile Kgosidalwa ◽

Osamah A. Hakami ◽

Carmel Kennedy ◽

Liam Grogan ◽

...

Keyword(s):

Immune Checkpoint ◽

Checkpoint Inhibitors ◽

Lung Metastases ◽

Incidental Finding ◽

Oral Prednisolone ◽

Thyroid Stimulating Hormone ◽

Free T4 ◽

Cross Sectional ◽

Remarkable Case ◽

Acth Deficiency

Abstract Background Immune checkpoint inhibitors (ICIs) are a novel class of oncological agents which are used to treat a number of malignancies. To date seven agents have been approved by the Food and Drug Administration (FDA) to treat both solid and haematological malignancies. Despite their efficacy they have been associated with a number of endocrinopathies. We report a unique case of hypophysitis, thyroiditis, severe hypercalcaemia and pancreatitis following combined ICI therapy. Case presentation A 46-year old Caucasian female with a background history of malignant melanoma and lung metastases presented to the emergency department with lethargy, nausea, palpitations and tremors. She had been started on a combination of nivolumab and ipilimumab 24 weeks earlier. Initial investigations revealed thyrotoxicosis with a thyroid stimulating hormone (TSH) of < 0.01 (0.38–5.33) mIU/L, free T4 of 66.9 (7–16) pmol/.L. TSH receptor and thyroperoxidase antibodies were negative. She was diagnosed with thyroiditis and treated with a beta blocker. Six weeks later she represented with polyuria and polydipsia. A corrected calcium of 3.54 (2.2–2.5) mmol/l and parathyroid hormone (PTH) of 9 (10–65) pg/ml confirmed a diagnosis of non-PTH mediated hypercalcaemia. PTH-related peptide and 1, 25-dihydroxycholecalciferol levels were within the normal range. Cross-sectional imaging and a bone scan out ruled bone metastases but did reveal an incidental finding of acute pancreatitis – both glucose and amylase levels were normal. The patient was treated with intravenous hydration and zoledronic acid. Assessment of the hypothalamic-pituitary-adrenal (HPA) axis uncovered adrenocorticotrophic hormone (ACTH) deficiency with a morning cortisol of 17 nmol/L. A pituitary Magnetic Resonance Image (MRI) was unremarkable. Given her excellent response to ICI therapy she remained on ipilimumab and nivolumab. On follow-up this patient’s thyrotoxicosis had resolved without anti-thyroid mediations – consistent with a diagnosis of thyroiditis secondary to nivolumab use. Calcium levels normalised rapidly and remained normal. ACTH deficiency persisted, and she is maintained on oral prednisolone. Conclusion This is a remarkable case in which ACTH deficiency due to hypophysitis; thyroiditis; hypercalcaemia and pancreatitis developed in the same patient on ipilimumab and nivolumab combination therapy. We postulate that hypercalcaemia in this case was secondary to a combination of hyperthyroidism and secondary adrenal insufficiency.

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Infants Diagnosed with Athyreosis on Scintigraphy May Have a Gland Present on Ultrasound and Have Transient Congenital Hypothyroidism

Hormone Research in Paediatrics ◽

10.1159/000514989 ◽

2021 ◽

pp. 1-8

Author(s):

Niamh McGrath ◽

Colin Patrick Hawkes ◽

Stephanie Ryan ◽

Philip Mayne ◽

Nuala Murphy

Keyword(s):

Thyroid Gland ◽

Congenital Hypothyroidism ◽

Thyroid Tissue ◽

Thyroid Stimulating Hormone ◽

Thyroid Ultrasound ◽

Free T4 ◽

Median Serum ◽

Thyroid Glands ◽

Rule Out

Scintigraphy using technetium-99m (99mTc) is the gold standard for imaging the thyroid gland in infants with congenital hypothyroidism (CHT) and is the most reliable method of diagnosing an ectopic thyroid gland. One of the limitations of scintigraphy is the possibility that no uptake is detected despite the presence of thyroid tissue, leading to the spurious diagnosis of athyreosis. Thyroid ultrasound is a useful adjunct to detect thyroid tissue in the absence of 99mTc uptake. Aims: We aimed to describe the incidence of sonographically detectable in situ thyroid glands in infants scintigraphically diagnosed with athyreosis using 99mTc and to describe the clinical characteristics and natural history in these infants. Methods: The newborn screening records of all infants diagnosed with CHT between 2007 and 2016 were reviewed. Those diagnosed with CHT and athyreosis confirmed on scintigraphy were invited to attend a thyroid ultrasound. Results: Of the 488 infants diagnosed with CHT during the study period, 18/73 (24.6%) infants with absent uptake on scintigraphy had thyroid tissue visualised on ultrasound (3 hypoplastic thyroid glands and 15 eutopic glands). The median serum thyroid-stimulating hormone (TSH) concentration at diagnosis was significantly lower than that in infants with confirmed athyreosis (no gland on ultrasound and no uptake on scintigraphy) (74 vs. 270 mU/L), and median free T4 concentration at diagnosis was higher (11.9 vs. 3.9 pmol/L). Six of 10 (60%) infants with no uptake on scintigraphy but a eutopic gland on ultrasound had transient CHT. Conclusion: Absent uptake on scintigraphy in infants with CHT does not rule out a eutopic gland, especially in infants with less elevated TSH concentrations. Clinically, adding thyroid ultrasound to the diagnostic evaluation of infants who have athyreosis on scintigraphy may avoid committing some infants with presumed athyreosis to lifelong levothyroxine treatment.

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What comprises the plate-like structure between the pancreatic head and the celiac trunk and superior mesenteric artery? A proposal for the term “P–A ligament” based on anatomical findings

Anatomical Science International ◽

10.1007/s12565-020-00597-1 ◽

2021 ◽

Author(s):

Satoru Muro ◽

Wachirawit Sirirat ◽

Daisuke Ban ◽

Yuichi Nagakawa ◽

Keiichi Akita

Keyword(s):

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Pancreatic Head ◽

Celiac Trunk ◽

Dorsal Side ◽

Uncinate Process ◽

Anatomical Basis ◽

The Right ◽

Upper Abdomen ◽

Macroscopic Examination

AbstractA plate-like structure is located posterior to the portal vein system, between the pancreatic head and roots and/or branches of two major arteries of the aorta: the celiac trunk and superior mesenteric artery. We aimed to clarify the distribution and components of this plate-like structure. Macroscopic examination of the upper abdomen and histological examination of the plate-like structure were performed on 26 cadavers. The plate-like structure is connected to major arteries (aorta, celiac trunk, superior mesenteric artery) and the pancreatic head; it contains abundant fibrous bundles comprising nerves, vessels, collagen fibers, and adipose tissue. Furthermore, it consists of three partly overlapping fibrous components: rich fibrous bundles (superior mesenteric artery plexus) fused to the uncinate process of the pancreas; fibrous bundles arising from the right celiac ganglion and celiac trunk that spread radially to the dorsal side of the pancreatic head and superior mesenteric artery plexus; and fibrous bundles, accompanied by the inferior pancreaticoduodenal artery, entering the pancreatic head. The plate-like structure is the pancreas–major arteries (aorta, celiac trunk, superior mesenteric artery) ligament (P–A ligament). The term “P–A ligament” may be clinically useful and can facilitate comprehensive understanding of the anatomy surrounding the pancreatic head and provide an anatomical basis for further pancreatic surgery studies.

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Thyroid Disease I: Hyperthyroidism in Pregnancy

10.2310/obg.19041 ◽

2020 ◽

Author(s):

Robert B. Martin ◽

Brian Casey

Keyword(s):

Hyperemesis Gravidarum ◽

Beta Blockers ◽

Thyroid Stimulating Hormone ◽

Thyroid Storm ◽

Care Level ◽

Hypermetabolic State ◽

Life Threatening ◽

Overt Hyperthyroidism ◽

In Pregnancy ◽

Stimulating Hormone

Thyroid physiologic adaptations in pregnancy may be confused with pathologic changes. Human chorionic gonadotropin rises early in pregnancy, stimulating thyrotropin secretion and suppressing thyroid stimulating hormone. These chemical changes are often seen in hyperemesis gravidarum and gestational transient thyrotoxicosis. Therefore, mild thyrotoxicosis may be difficult to differentiate from early pregnancy thyroxine stimulation. However, overt hyperthyroidism usually includes classic symptoms seen outside of pregnancy in addition to suppressed TSH and T4 levels. Treatment includes thionamides propylthiouracil and methimazole. Thyroid ablation is contraindicated in pregnancy. Often, in affected women, the fetus is euthyroid, but neonates can develop hyper or hypothyroidism with or without a goiter. Lastly, thyroid storm, though rare, is life threatening. Often presenting as a hypermetabolic state with cardiomyopathy and pulmonary hypertension, it generally results from decompensation from preeclampsia, anemia, sepsis, or surgery. Treatment requires intensive care level management, with initiation of thionamides, iodine, and beta blockers. This review contains 2 figures, 4 tables and 38 references. Keywords: Thyroid-releasing hormong, thyroid-stimulating hormone, thyromegaly, thyroid-stimulating immunoglobulins, thryotoxicosis, thionamides, thyroid storm

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Orbital metastasis as primary clinical manifestation of thyroid carcinoma: case report and literature review

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302008000900014 ◽

2008 ◽

Vol 52 (9) ◽

pp. 1497-1500 ◽

Cited By ~ 16

Author(s):

Francisco Dário Rocha Filho ◽

Gabrielle Gurgel Lima ◽

Francisco V. de Almeida Ferreira ◽

Michelle Gurgel Lima ◽

Miguel N. Hissa

Keyword(s):

Thyroid Carcinoma ◽

Clinical Manifestation ◽

Palliative Chemotherapy ◽

Distant Metastases ◽

Histopathological Analysis ◽

Free T4 ◽

Follicular Variant ◽

Orbital Metastasis ◽

Uncommon Case ◽

The Right

Capillary thyroid carcinoma (PTC) is the most common neoplasm of thyroid. It usually grows slowly and is clinically indolent, although rare, its aggressive forms with local invasion or distant metastases can occur. Metastatic thyroid carcinoma rarely involves the orbit. We reported an uncommon case of orbital metastasis of PTC. A 66-years-old woman presented proptosis of the right eye. The biopsy of the tumor in orbit revealed metastatic thyroid carcinoma. The ultrasensitive TSH level was 1,34 mUI/L and free T4 level was 1,65 ng/dL. A total thyroidectomy was performed and histopathological analysis of the nodule revealed follicular variant of papillary thyroid carcinoma. Currently, the patient has been receiving palliative chemotherapy with Clodronate Disodium. The importance of the case is due to its unusual presentation, which emerged as a primary clinical manifestation. Although rare, thyroid carcinoma should be suspected in orbit metastasis.

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