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Apathetic Thyrotoxicosis with Thyrotoxic Crisis

Apathetic Hyperthyroidism with Thyrotoxic Crisis or Storm


Presentation

  • Improve your interpretation of presenting symptoms with 38 new topics and 40 new images in the Differential Diagnosis section, and optimize patient care with more than 250 new figures and tables.[books.google.com]
  • Improve your interpretation of presenting symptoms with 39 new topics in the Differential Diagnosis section, and optimize patient care with 12 new tables in the Clinical Practice Guidelines section.[books.google.com]
  • Types of presentation Goitre Occurs in almost all presentations of Grave’s disease – in which case it is usually diffuse and symmetrical The eye signs – Ophthalmopathy Occurs in 50% of cases of Grave’s disease This is the typical presentation of Grave[almostadoctor.co.uk]
  • (apathetic hyperthyroidism) 100 results Apathetic thyrotoxicosis presenting with diabetes mellitus.[unboundmedicine.com]
  • Case presentation A 59-year-old Caucasian man was admitted with lethargy and progressive weight loss for 6 to 8 months prior to presentation.[jmedicalcasereports.biomedcentral.com]
Goiter
  • Topics covered include the following: thyroid synthesis and physiology; hyperthyroidism; hypothyroidism; thyroid nodules; goiter; differentiated thyroid cancer; subacute, silent, and postpartum thyroiditis; thyroid and pregnancy; thyroid and the elderly[books.google.com]
  • 242.90: 242.91 - Thyrotoxicosis without mention of goiter or other cause, with mention of thyrotoxic crisis or storm[emedcodes.com]
  • ) ( Figure 224-0.1 ) Most common of all hyperthyroidism (85% of all cases) Associated with diffuse goiter, ophthalmopathy, and local dermopathy Toxic multinodular goiter Second most common cause of hyperthyroidism Toxic nodular (adenoma) goiter ( Figure[mhmedical.com]
  • […] thyroid disease or other autoimmune diseases Previous nontoxic multinodular goiter Signs and symptoms of thyrotoxicosis No differential features Goiter a Features of vascular goiter b Multinodular goiter or solitary nodule Ocular signs and symptoms Features[empendium.com]
  • Thyrotoxicosis without goiter OR other cause[icd9data.com]
Weight Loss
  • Lack of weight gain that is normal during pregnancy, or significant weight loss, despite having normal appetite.[hyperthyroidismsymptomsx.com]
  • Case presentation A 59-year-old Caucasian man was admitted with lethargy and progressive weight loss for 6 to 8 months prior to presentation.[jmedicalcasereports.biomedcentral.com]
  • Signs and SymptomsSigns and Symptoms – Tremulousness or jitteriness – Exophthalmos – Weight loss despite excellent appetite – hypermetabolic state – Insomnia – Fatigue – Palpitations – Heat intolerance – Sweating – Diarrhea – Deterioration in handwriting[slideshare.net]
  • Hyperthyroidism can accelerate your body's metabolism, causing unintentional weight loss and a rapid or irregular heartbeat. Several treatments are available for hyperthyroidism.[mayoclinic.org]
  • These apathetic patients were significantly older and had a longer duration of symptoms and greater weight loss. The study group had a rather typical apathetic, placid, or depressed appearance often thought to represent "old age depression."[annals.org]
Fatigue
  • Other symptoms of thyroid storm include chest pain,palpitations, shortness of breath,delirium,confusion, psychosis, stupor, and fatigue. Fatal health complications include heart attack and stroke.[hyperthyroidismsymptomsx.com]
  • Fatigue B. Palpitations C. Weight Loss D. Heat intolerance E. All the above 42 2. The most common etiology of hyperthyroidism is A. Toxic Multinodular B. Graves C. Toxic Nodular D. Amiodarone induces 43 3.[slideplayer.com]
  • Presentation Symptoms/Physical exam Hypothyroidism Hyperthyroidism Cold intolerance ( heat production) Heat intolerance ( heat production) Weight gain, appetite Weight loss, appetite Hypoactivity, lethargy, fatigue, weakness Hyperactivity Constipation[medbullets.com]
  • In fact, I am normally fatigued, low mood etc. This matches the AT descriptions I have been reading. I don't remember any doctors mentioning this. I am wondering whether I should be having any different treatment, or test to confirm this.[healthunlocked.com]
  • They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that[icdlist.com]
Congestive Heart Failure
  • Cardiovascular symptoms, atrial fibrillation, and congestive heart failure were common. They typically had evidence of a moderately severe proximal myopathy. Thyromegaly, although usually present, was not prominent and was usually multinodular.[annals.org]
  • Progression to congestive heart failure, refractory pulmonary edema, circulatory collapse, coma, and death may occur within 72 h. Fever ranges from 38?C (100.4?F) to 41?C (105.8?F).[emjournal.net]
  • heart failure.  Cardiac hypertrophy has been reported in thyrotoxicosis of different etiologies.  Severe acropachy can be disabling and can lead to total loss of hand function - clubbing of fingers with osteoarthropathy, including periosteal new bone[slideshare.net]
  • The Japanese Thyroid Association (JTA) criteria categorize patients based on aggregate presence of certain clinical features (CNS, fever, tachycardia, congestive heart failure, GI).[mdcalc.com]
  • These include a rapid heart rate, a heart rhythm disorder called atrial fibrillation that increases your risk of stroke, and congestive heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.[mayoclinic.org]
Thyroid Nodule
  • Topics covered include the following: thyroid synthesis and physiology; hyperthyroidism; hypothyroidism; thyroid nodules; goiter; differentiated thyroid cancer; subacute, silent, and postpartum thyroiditis; thyroid and pregnancy; thyroid and the elderly[books.google.com]
  • Other causes include thyroid nodules, thyroiditis, consuming too much iodine, and taking too much synthetic thyroid hormone. The symptoms can vary from person to person.[icdlist.com]
  • Cytology is used to classify thyroid nodules as malignant (thyroid cancer), suspicious, or nonmalignant in order to determine indications for surgery.[empendium.com]
  • Hyperfunctioning thyroid nodules (toxic adenoma, toxic multinodular goiter or Plummer's disease). This form of hyperthyroidism occurs when one or more adenomas of your thyroid produce too much T4.[mayoclinic.org]
  • Radioiodine (I-123) or 99m Technetium scan typically shows areas of increased (“hot” or “warm”) and decreased (“cold” or “cool”) uptake corresponding to the multiple thyroid nodules .[ocw.tufts.edu]
Failure to Thrive
  • Fred Ferri’s popular "5 books in 1" format provides quick guidance on menorrhagia, Failure to Thrive (FTT), Cogan’s syndrome, and much more.[books.google.com]
Tachycardia
  • Circulation: Tachycardia is common, either sinus tachycardia (most common rhythm) or atrial fibrillation (most common dysrhythmia). Supraventricular and ventricular dysrhythmias, including ventricular fibrillation, may occur.[cdemcurriculum.com]
  • Cardiac symptoms may include congestive heart failure, which is often refractory to therapy, tachycardia, and a widened pulse pressure.[thebigl.co]
  • A life-threatening thyrotoxic crisis (ie, thyroid storm) can occur: fever, tachycardia, neurologic abnormalities, and hypertension, followed by hypotension and shock.[slideshare.net]
  • The most common cardiac manifestations of thyrotoxicosis are resting sinus tachycardia, supraventricular tachycardia including atrial fibrillation and atrial flutter with or without cardiac failure.[jmedicalcasereports.biomedcentral.com]
  • Tachycardia, fever, hyperkinesis, tremor, proximal myopathy, periodic paralysis, bulbar palsy and hypercalcaemia respond.[aic.cuhk.edu.hk]
Cardiomegaly
  • His chest X-ray showed cardiomegaly but no pulmonary oedema. However his 12-lead electrocardiogram showed complete heart block with underlying atrial fibrillation (Figure 1 ).[jmedicalcasereports.biomedcentral.com]
  • Most patients will have weight loss, evidence of cardiomyopathy, myopathy and may have atrial fibrillation, congestive heart failure, cardiomegaly and muscle weakness. Thyroid storm .[ocw.tufts.edu]
  • The chest radiographic finding noted in some of these patients was essentially that of increased cardiothoracic ratio suggestive of cardiomegaly.[pjms.com.pk]
Bounding Pulse
  • The high cardiac output produces a bounding pulse, widened pulse pressure, and an aortic systolic murmur, and can lead to worsening of angina or heart failure in the elderly or those with preexisting heart disease [19].[webedcafe.com]
Excessive Tearing
  • Signs and symptoms of Graves' ophthalmopathy include: Dry eyes Red or swollen eyes Excessive tearing or discomfort in one or both eyes Light sensitivity, blurry or double vision, inflammation, or reduced eye movement Protruding eyeballs When to see a[mayoclinic.org]
  • The earliest manifestations of GO are a sensation of grittiness, eye discomfort, and excess tearing.[webedcafe.com]
  • Table 1 Clinical features of thyroid-associated ophthalmopathy Signs and symptoms Assessment Approximate frequency a (%) Lid lag, lid retraction Measure lid fissure width 50–60 Grittiness, discomfort, excessive tearing, retrobulbar pain, periorbital oedema[enetmd.com]
Osteoporosis
  • Updated clinical guidelines for diabetes, lipid disorders, obesity management, osteoporosis, and more, as well as essential treatment updates for the medical management of acromegaly, Cushing's Disease, hypercalcemia, and diabetes mellitus.[books.google.com]
  • Hyperthyroidism can aggressively hasten the progression of osteoporosis and heart diseases, thus increasing the risk of stroke or heart failure.[hyperthyroidismsymptomsx.com]
  • Constipation Diarrhea reflexes reflexes Bradycardia Tachycardia, palpitations, arrhythmias Dry, cool skin; coarse, brittle hair Warm, moist skin; fine hair Diastolic hypertension (Na/H20 retention) Systolic hypertension Myxedema (facial/periorbital) Osteoporosis[medbullets.com]
  • .  Cardiac complications and psychocognitive complications  Osteoporosis in men and women. The effect can be particularly devastating in women, in whom the disease may compound the bone loss secondary to chronic anovulation or menopause.[slideshare.net]
  • Untreated hyperthyroidism can also lead to weak, brittle bones (osteoporosis). The strength of your bones depends, in part, on the amount of calcium and other minerals they contain.[mayoclinic.org]
Suggestibility
  • Access full-color images and more than 90 online-only topics at Expert Consult, as well as EBMs, Suggested Reading, Patient Teaching Guides, and additional algorithms.[books.google.com]
  • Access full-color images and 65 online-only topics at Expert Consult, as well as online-only contents including EBMs, Suggested Reading, Patient Teaching Guides, and additional algorithms.[books.google.com]
  • Next Steps Evidence Creator Insights Advice BWPS 45 is highly suggestive of thyroid storm; consider rapid and aggressive multimodal management in ICU. BWPS 25-44 suggests impending thyroid storm; consider thionamides, symptom management.[mdcalc.com]
  • Toxic adenomas are encapsulated and cellular, sometimes with little evidence of follicle formation, and occasionally containing unusual cell forms suggesting malignant change.[enetmd.com]
  • Plasma cortisol levels have been observed to be inappropriately low for the degree of stress, suggesting a lack of adrenal reserve.[emjournal.net]
Withdrawn
  • Although β-blockers will rapidly alleviate symptoms in all types of hyperthyroidism, definitive treatment is also necessary, and when euthyroidism is restored β-blockers can be gradually withdrawn.[enetmd.com]
Manic Behavior
  • Symptoms vary from restlessness, anxiety, and emotional lability, manic behavior, agitation, and psychosis, to mental confusion, obtundation, and coma. Extreme muscle weakness can occur.[emjournal.net]
Confusion
  • Other symptoms of thyroid storm include chest pain,palpitations, shortness of breath,delirium,confusion, psychosis, stupor, and fatigue. Fatal health complications include heart attack and stroke.[hyperthyroidismsymptomsx.com]
  • On examination, the patient appeared ill, prostrated, and confused. Blood pressure was 190/120 mm Hg, pulse was 148/min and irregular, and respiratory rate was 20/min. Mucous membranes were dry and a pulse deficit of 20 was present.[thefreelibrary.com]
  • Skin usually moist and warm - confusion, fits, coma, muscle weakness. Very common. Features of UMN lesions have been described as has rhabdomyolysis and sudden onset of thyrotoxic periodic paralysis - arrhythmias, cardiac failure.[aic.cuhk.edu.hk]
  • About 1 percent of patients with Graves’ disease develop myasthenia gravis, producing an occasional confusing clinical situation.[emjournal.net]
  • Specific Code heart E05.90 - see also Hyperthyroidism Failure, failed Note: heart failure stages A, B, C, and D are based on the American College of Cardiology and American Heart Association stages of heart failure, which complement and should not be confused[icd10data.com]
Apathy
  • The patient had a recent history of decreased mentation and apathy, and laboratory findings were found to be consistent with hyperthyroidism.[thefreelibrary.com]
  • Apathy, or symptoms of depression? Often seen in elderly – apathetic hyperthyroidism. Are there associated cardiovascular complaints? Dyspnea? Chest pain? Acute myocardial infarction can trigger or be triggered by thyroid storm.[cdemcurriculum.com]
  • Overt thyrotoxic crisis : Fever; extreme agitation and worsening of psychotic symptoms; sometimes somnolence, apathy, or even coma; in some cases, status epilepticus; sudden worsening of cardiovascular symptoms (severe tachycardia, atrial fibrillation[empendium.com]
  • Apathy, stupor and coma may occur. Laboratory evaluation of thyrotoxicosis begins with a measurement of TSH. If TSH is suppressed ( Figure 1.[ocw.tufts.edu]
Hand Tremor
  • They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that[icdlist.com]

Workup

  • HYPERTHYROIDISM (THYROTOXICOSIS) Workup This disorder is the result of an excessive concentration of circulating thyroid hormone.[thebigl.co]
  • Truly refractory disease is rarely found in a properly conducted workup. Postgraduate Medicine 2000;107:123-45. 33. Klein I, Ojomata K. Thyroid hormone and blood pressure regulation.[pjms.com.pk]
  • PubMed PMID: 11589682. 2) Serum antibodies to thyroperoxidase ( TPO )—TPO Ab—and antibodies to thyroglobulin ( Tg )—Tg Ab—(least specific): Measurement of TPO Ab and Tg Ab is not suggested for the workup of patients with low TSH values, Weak recommendation[empendium.com]
Hepatic Necrosis
  • Jaundice and tender hepatomegaly due to passive congestion of the liver, or even hepatic necrosis, have been reported. Jaundice is a poor prognostic sign. LABORATORY There are no laboratory tests that confirm thyroid storm.[emjournal.net]

Treatment

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  • Make the best clinical decisions with an enhanced emphasis on evidence-based practice and expert opinions on treatment strategies. Zero in on the most relevant and useful references with the aid of a more focused, concise bibliography.[books.google.com]
  • Ingbar’s The Thyroid: A Fundamental and Clinical Text, 10th Edition has been extensively revised and streamlined to deliver the most comprehensive coverage of the thyroid including anatomy, development, biochemistry, physiology, pathophysiology, and treatment[books.google.com]
  • Up to 30% of women can cease treatment by the third trimester. The baby should be checked straight after birth, as treatment in this way can cause a goitre.[almostadoctor.co.uk]
  • Surgical Treatment (Thyroidectomy) 1.[empendium.com]

Prognosis

  • Decreasing pulse rate and BP with the development of shock are associated with poor prognosis - vomiting, diarrhoea.[aic.cuhk.edu.hk]
  • Presence of jaundice suggests especially poor prognosis. Ultimately, thyroid storm is a clinical diagnosis and requires prompt recognition and treatment.[mdcalc.com]
  • The nature and prognosis of heart disease in thyrotoxicosis. Q J Med 1959;28:347-70. 30. Yang YS, Chang CC, Su DH. Unusual presentation of thyrotoxicosis as bradycardia, acute renal failure and hyperuricaemia in an elderly patient.[pjms.com.pk]
  • […] tachycardia (usually out of proportion to the degree of fever), central nervous system manifestations (varying from confusion to coma), and gastrointestinal dysfunction with nausea, vomiting, or even jaundice in severe cases, which usually denotes a poor prognosis[thefreelibrary.com]
  • Prognosis Although spontaneous remission occurs in Graves’ disease, its exact frequency is unknown and is unlikely to be more than 10%, with no guarantee of persistence. Remission does not occur in other types of hyperthyroidism.[enetmd.com]

Etiology

  • […] most common) Idiopathic causes Ablative therapy Iodine deficiency May be transient Pathophysiology is unclear but may be viral in nature 23 Hypothyroidism Etiologies of Hypothyroidism Primary Autoimmune etiologies Hashimotos is the most common Idopathic[slideplayer.com]
  • .  Cardiac hypertrophy has been reported in thyrotoxicosis of different etiologies.  Severe acropachy can be disabling and can lead to total loss of hand function - clubbing of fingers with osteoarthropathy, including periosteal new bone formation,[slideshare.net]
  • Therapy for hyperthyroidism depends on the etiology.[thebigl.co]
  • However, these patients are often critically ill and the complications or inciting etiology of the patient’s thyroid storm may require active airway intervention.[cdemcurriculum.com]
  • Serum TSH measurement is the best test because TSH is suppressed in hyperthyroid patients except in the rare instance when the etiology is a TSH-secreting pituitary adenoma or pituitary resistance to the normal inhibition by thyroid hormone.[merckmanuals.com]

Epidemiology

  • Epidemiology/Pathophysiology Graves' disease is the most common form of hyperthyroidism accounting for 60-70% of all cases. It occurs in up to 3% of the population.[ocw.tufts.edu]
  • These antibodies stimulate the thyroid gland to produce more T3 and T4 Epidemiology Can occur at any age Peak onset age 40-60 F:M 5-10 : 1 Aetiology Environment triggers include: High iodine intake Stress Smoking Smoking is also a major risk factor in[almostadoctor.co.uk]
  • Amer J Epidemiology 2003;157:1101-7. 17. Rojeski MT, Gharib H. Nodular thyroid disease. New Eng J Medicine 1985;4:249-53. 18. Czarkowski M, Hilgertner L, Powalowski T, Radomski D, Mikulska M.[pjms.com.pk]
  • Epidemiology The prevalence of thyrotoxicosis in white people is 2 to 3% in women and 0.2 to 0.3% in men. The peak age of onset for Graves’ disease is between 20 and 50 years of age, whereas toxic multinodular goitre occurs more often in later life.[enetmd.com]
Sex distribution
Age distribution

Pathophysiology

  • 12 - 912 ページ Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text, 10th Edition has been extensively revised and streamlined to deliver the most comprehensive coverage of the thyroid including anatomy, development, biochemistry, physiology, pathophysiology[books.google.com]
  • Epidemiology/Pathophysiology Graves' disease is the most common form of hyperthyroidism accounting for 60-70% of all cases. It occurs in up to 3% of the population.[ocw.tufts.edu]
  • […] secretion Occurs more frequently in women (0.6 to 5.9 %) The most common etiologies are Primary thyroid failure due to autoimmune diseases (Hashimoto thyroiditis is the most common) Idiopathic causes Ablative therapy Iodine deficiency May be transient Pathophysiology[slideplayer.com]
  • PATHOPHYSIOLOGY The exact pathogenesis of thyroid storm has not been defined. It is attractive to attribute storm to excess thyroid hormone production or secretion.[emjournal.net]
  • In Laragh JH, Brenner BM, editors, Hypertension, pathophysiology, diagnosis and management. 2nd Edition, New York Raven Press 1995;2247-62. Professional Medical Publications Room No. 522, 5th Floor, Panorama Centre Building No. 2, P.O.[pjms.com.pk]

Prevention

  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • In brief: The management strategy for thyroid storm revolves around preventing peripheral effects of raised thyroid hormone levels, and preventing the ongoing increase of said levels by inhibiting the synthesis and release of thyroid hormone.[derangedphysiology.com]
  • Chlorpromazine 25-50 mg 4-6 hrly to prevent shivering - fluid replacement.[aic.cuhk.edu.hk]
  • […] relases of hormone (after synthesis blockade intiated) Iodine Iaponoric acid (Telepaque) 1 gm IV q8h for the first 24 h, then 500 mg bid or Potassium iodide (SSKI) 5 drops PO q6h or Lugol solution 8-10 drops PO q6h Lithuim mg PO every day Prevent peripheral[slideplayer.com]

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