Basida Brinda, Zalavadiya Nirav, Ismail Rana, Krayem Hicham
Department of Internal Medicine, Detroit Medical Center Sinai-Grace Hospital, Detroit, USA.
Department of Pulmonary and Critical Care Medicine, Detroit Medical Center Sinai-Grace Hospital, Detroit, USA.
Cureus. 2021 Mar 31;13(3):e14219. doi: 10.7759/cureus.14219.
Thyroid storm is an extremely rare yet life-threatening medical emergency. It results from the decompensation of undiagnosed or undertreated hyperthyroidism in the presence of an acute stressor such as trauma to the thyroid, infections, acute iodine load, withdrawal from the antithyroid medication, or surgical procedures (including thyroid surgery). Clinical features of thyroid storm include hyperthermia, tachycardia, respiratory distress, gastrointestinal and hepatic symptoms, and central nervous system dysfunction. It is primarily a clinical diagnosis, further aided by abnormal thyroid function tests. Thyroid storm is associated with significant mortality and morbidity - the latter mostly related to complications from thyrotoxicosis or hyperthyroidism. Treatment with iodine (or iodide-ionized active form of iodine) supplements or with radioactive iodine, also known as radioiodine, such as in the treatment of thyroid cancer, is a common and mostly safe practice; however, iodine contrast in tomography imaging may precipitate a thyroid storm in sporadic cases. Here, we report a remarkable case of a 62-year-old African American female with a history of total thyroidectomy secondary to follicular thyroid cancer three years before the current presentation; she developed left lung pneumonia complicated by thyroid storm status post a computed tomography angiogram of the abdomen. She exhibited signs and symptoms of thyrotoxicosis a few days after receiving the iodinated contrast. The recommended daily iodide intake for adults with hyperthyroidism is about 150 mcg per day, while a computed tomography scan exposes patients to 14 to 35 million mcg of iodinated contrast at once, which could have triggered a storm. In this case, the patient was diagnosed with thyroid storm, which was presumed to be a consequence of the Jod-Basedow phenomenon secondary to metastatic thyroid carcinoma lesions discovered later. This clinical diagnosis was reinforced by laboratory results showing elevated serum free T4 and undetectable thyroid-stimulating hormone. She was treated with supportive measures, steroids, beta-blockers, and antithyroid medications with a positive outcome. This case demonstrated that, in the setting of recurrent metastatic thyroid cancer, clinicians should approach the use of intravenous iodine medium contrast in imaging with some level of caution when dealing with patients at risk of thyrotoxicosis or with underlying hyperthyroidism state at the brink of a storm.
甲状腺危象是一种极其罕见但危及生命的医疗急症。它是由于未诊断或治疗不充分的甲状腺功能亢进在急性应激源（如甲状腺创伤、感染、急性碘负荷、停用抗甲状腺药物或外科手术（包括甲状腺手术））存在的情况下失代偿所致。甲状腺危象的临床特征包括高热、心动过速、呼吸窘迫、胃肠道和肝脏症状以及中枢神经系统功能障碍。它主要是一种临床诊断，甲状腺功能检查异常可进一步辅助诊断。甲状腺危象与显著的死亡率和发病率相关——后者大多与甲状腺毒症或甲状腺功能亢进的并发症有关。用碘（或碘的离子化活性形式）补充剂或放射性碘（也称为放射碘）进行治疗，如在甲状腺癌治疗中，是一种常见且大多安全的做法；然而，断层扫描成像中的碘造影剂在散发病例中可能引发甲状腺危象。在此，我们报告一例引人注目的病例，一名62岁非裔美国女性，在本次就诊前三年因滤泡性甲状腺癌接受了全甲状腺切除术；她在腹部计算机断层血管造影术后发生左肺肺炎并并发甲状腺危象。她在接受碘化造影剂几天后出现了甲状腺毒症的体征和症状。甲状腺功能亢进的成年人每日推荐碘摄入量约为150微克，而一次计算机断层扫描会使患者接触1400万至3500万微克的碘化造影剂，这可能引发危象。在本病例中，患者被诊断为甲状腺危象，推测是后来发现的转移性甲状腺癌病灶继发的约德 - 巴塞多现象的结果。实验室结果显示血清游离T4升高且促甲状腺激素检测不到，这强化了这一临床诊断。她接受了支持性措施、类固醇、β受体阻滞剂和抗甲状腺药物治疗，结果良好。该病例表明，在复发性转移性甲状腺癌的情况下，临床医生在为有甲状腺毒症风险或处于甲状腺危象边缘的潜在甲状腺功能亢进状态的患者进行成像时，应谨慎使用静脉碘造影剂。
