Amiodarone induced thyrotoxicosis thyroid disease manager. Pathology outlines amiodarone induced hyperthyroidism. The autoregulatory controls of the thyroid must fail for this to occur. Clinical course and predictors of outcome david conen, ludovic melly, christoph kaufmann, stefan bilz, peter ammann, beat schaer, christian sticherling, beat muller, stefan osswald this study evaluated the clinical course and predictors of longterm outcome in 84 patients with amiodarone induced thyrotoxicosis ait. Given the new onset graves disease, administration of amiodarone may have exacerbated ventricular arrhythmias through amiodarone induced thyrotoxicosis. This is a condition called type i amiodarone induced thyrotoxicosis hyperthyroidism. Amiodaroneinduced thyrotoxicosis suggestive of thyroid. These adverse effects may occur in patients with or without preexisting thyroid disease. Thyrotoxicosis, the clinical syndrome resulting from increased free thyroxine t4 andor free triiodothyronine t3 levels, has a broad spectrum of etiologies fig. It is caused by an activating antibody which targets the tsh receptor.
A read is counted each time someone views a publication summary such as the title, abstract, and list of authors, clicks on a figure, or views or downloads the fulltext. Amiodarone induced thyrotoxicosis ait, may occur early after taking the drug, during usage for several years and even long time after withdrawl of the drug because it is stored in tissues and slowly released from them. Amiodarone induced thyrotoxicosis ait type 2 is selflimiting in nature, but most physicians are reluctant to continue amiodarone. Type 1 occurs in patients with underlying thyroid pathology such as autonomous nodular goiter, graves disease or hashimotos thyroiditis. Approach to the patient with amiodaroneinduced thyrotoxicosis. We have not encountered this situation in practice 16.
Amiodarone induced thyrotoxicosis, types i and ii, is a known adverse effect occurring in up to 3% of patients. Symptoms are similar to those in graves disease and diagnosis is based on history, examination findings, and by testing thyroid functions. Management of amiodaronerelated thyroid problems ncbi. This case highlights the importance of measuring serum t3 and thyroidstimulating hormone concentrations in addition to t4 and free t4 concentrations when there is. Some experts distinguish between thyrotoxicosis and hyperthyroidism by restricting the latter term to describe the conditions associated with excess synthesis and secretion of thyroid hormones from the thyroid gland. A patient with underlying hashimotos thyroiditis developed amiodarone induced thyrotoxicosis type 1 that was successfully treated using methimazole in combination with potassium iodide. Psychosis crisis associated with thyrotoxicosis due to graves. Amiodarone induced thyrotoxicosis is a predictor of adverse cardiovascular outcome. This disease result from an excess of circulating thyroid hormone. Graves disease, toxic multinodular goitre, toxic adenoma and thyroiditis account for most presentations of thyrotoxicosis. Despite the concerns inherent to severe cardiac disease, total thyroidectomy can be performed safely in patients with resistant amiodarone induced. The pathogenesis of ait is often due to iodine induced excessive thyroid hormone synthesis, especially in patients with underlying thyroid disease. Lithium is an integral drug used in the management of acute mania, unipolar and bipolar depression and prophylaxis of bipolar disorders.
Graves disease thyroid adenoma druginduced background. Acute and emergency care for thyrotoxicosis and thyroid storm. An epidemic of thyrotoxicosis students guide learning objectives after completing this case study, the participant should be able to. Amiodarone induced thyrotoxicosis ait is not an uncommon complication in countries with low iodine intake. Diagnosis and management of thyrotoxicosis europe pmc. It is known to produce thyroid abnormalities ranging from abnormal thyroid function testing to overt hypothyroidism or hyperthyroidism. Hyperthyroidism is an imbalance of metabolism caused by overproduction of thyroid hormone.
The aim of this study is to describe three different cases of patients with amiodarone induced thyrotoxicosis and discuss the. Amiodarone induced thyrotoxicosis ait develops in 3% of amiodaronetreated patients in north america. Central hypothyroidism may be induced by inhibition of thyroidstimulating hormone bexarotene or corticosteroids or by immunological mechanisms anti ctla4. Here we describe a very rare case of thyrotoxicosis with painless thyroiditis induced ami. Gross appearance of the thyroid showing homogeneous, beefyred, richincolloid thyroid parenchyma a and 2 welldemarcated, light yellow nodules arrowsb. Diagnosis and treatment are closely linked, because the diagnostic problems may affect the therapeutic approach and lead to suboptimal treatment and delayed resolution of dysfunction. A fatal case of recurrent amiodarone induced thyrotoxicosis after percutaneous tracheotomy. Thyrotoxicosis in the case of an activated tsh receptor or g protein is permanent until all thyroid tissue has been removed 9,14,15. The rapid and irregular heartbeat produced by af increases the risk of blood clot formation inside the heart. The aim of the present study was to show, that total thyroidectomy under general anaesthesia in patients with amiodarone induced thyrotoxicosis ait is.
Despite antithyroid drug therapy, some patients demonstrated refractory hyperthyroidism. Type 1 is associated with an underlying disorder of the gland that becomes clinically evident because of the high intrathyroidal iodine content, which acts as a trigger for hyperthyroidism. Amiodarone is a potent antiarrhythmic agent, indicated for the treatment of refractory arrhythmias, which may lead to thyrotoxicosis. Thyroid dysfunction induced by amiodarone therapy treatment. This increase in iodine delivery and uptake can increase thyroid hormone production and release. Drugs used to treat thyrotoxicosis the following list of medications are in some way related to, or used in the treatment of this condition. An other condition which release stored hormone such as thyroiditis. Despite the potential risks of anaesthesia associated with uncontrolled thyrotoxicosis, thyroidectomy should be considered in the setting of life.
It can result in thyrotoxicosis, an outcome of excessive thyroid hormone. Hyperthyroidism includes a range of endocrine disorders caused by overactive thyroid glands or thyroid stimulators in the blood. Proportion of type 1 and type 2 amiodarone induced thyrotoxicosis has changed over a 27year period in italy. He subsequently reverted to sinus rhythm and his medication was stopped 1 year prior to presentation. Associated with worsening cardiac arrhythmia with recurrence of atrial fibrillation and palpitations ncbi amiodarone induced thyrotoxicosis may occur suddenly in patients treated with amiodarone for several years, likely due to its long half life, lipid solubility and accumulation in almost all tissue. Amiodarone induced thyrotoxicosis ait is a clinical condition that is notoriously difficult to manage. For full access to this pdf, sign in to an existing. A medline literature search was performed of articles. Describe the roles, responsibilities, and relationships of federal versus state public health agencies in a field investigation.
Although amiodarone is regarded as a highly effective antiarrhythmic agent, its use may lead to alterations in thyroid gland function andor thyroid hormone metabolism, partly because of its rich iodine content. Clinical characteristics of amiodaroneinduced thyrotoxicosis. A 69yearold man presented with a 6week history of shortness of breath on exertion, unintentional weight loss, altered bowel habits and lethargy. Graves disease is the commonest cause of thyrotoxicosis being more common in females than males. Type 2 ait is a result of amiodarone causing a subacute thyroiditis with release of preformed thyroid hormones into the circulation.
The mechanism for amiodaroneinduced hyperthyroidism and. Surgical management of amiodaroneinduced thyrotoxicosis. However, one study in the united kingdom found that the distinction between the 2 subtypes of ait was not essential for treatment and found no difference in overall outcome between the 2 groups treated with thionamides alone. Amiodarone induced thyrotoxicosis ait is a clinically. Thyrotoxicosisinduced acute myocardial infarction due to. Total thyroidectomy in a patient with amiodarone induced thyrotoxicosis and thiamazole related hepatotoxicity marquescunha m, costa g, gomes m, moura f amiodarone induced thyrotoxicosis is a rare but serious complication of amiodarone use, especially in patients with severe cardiac disease. Amiodarone induced thyrotoxicosis ait is generally believed to result from increased hormonal synthesis related to the iodine overload. The aim of this study is to describe three different cases of patients with amiodaroneinduced thyrotoxicosis and discuss the clinical and laboratorial aspects, and. Hyperthyroid thyrotoxicosis medicine endocrinology thyroid disorders. Oct 08, 2018 differentiation of the 2 types of thyrotoxicosis is essential for determining the best management of the disease.
Members of the european thyroid association eta with clinical interests were asked to answer a questionnaire on the diagnosis and management. Jun 10, 2006 in all forms of overt thyrotoxicosis, the serum value of tsh is decreased and the measurements of free thyroxine t4 or free thyroxine index or free triiodothyronine t3, or both, are raised. Iodine induced thyrotoxicosis is usually not graves or basedows disease but toxic nodular goiter. Amiodarone induced toxic nodular goiter, a form of iodine induced thyrotoxicosis, was described in europe where large nodular goiters are more prevalent than in the united states. Total thyroidectomy in a patient with amiodarone induced. The thyrotoxicosis is mediated by amiodarones iodine content. Thyrotoxicosis of pregnancy can present unique diagnostic challenges and, if untreated, is associated with increased risks of adverse maternal, fetal, and neonatal complications. Prevention and treatment of iodineinduced thyrotoxicosis. A sestamibi scan uses a tracer that shows good uptake by the thyroid gland in type 1 amiodarone induced thyrotoxicosis ait1 but almost no uptake in type 2 ait2. Amiodaroneinduced thyrotoxicosis and thyroid cancer. There was no tenderness of the thyroid on palpation.
The thyrotoxic crisis is a medical emergency caused by an. Amiodarone induced thyrotoxicosis ait is a clinical condition fraught with difficulties and uncertainties both from the diagnostic and therapeutic standpoints. Thyrotoxicosis is a condition caused by an increase in the levels of thyroid hormone circulating in the blood. He was diagnosed with atrial fibrillation 2 years previously and started on amiodarone and warfarin. Special article 2016 american thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis douglas s. Total thyroidectomy for amiodaroneinduced thyrotoxicosis. Thyroid damage has recently been incriminated as a pathophysiological mechanism. Pharmacological sciences management of thyrotoxic crisis. Ventricular fibrillation associated with graves disease. Thyrotoxicosis factitia thyroid toxicity exogenous. Of the cardiovascular medications given, sotalol is the most common cause of drug induced tdp, occurring in. Although amiodarone induced hypothyroidism poses no particular problem, amiodarone induced thyrotoxicosis ait is a diagnostic and therapeutic challenge.
Overview of the clinical manifestations of hyperthyroidism in. Patients with painless thyroiditis show a thyrotoxic phase during the early stages. Ait is primarily related to excess iodineinduced thyroid hormone. Amiodaroneinduced thyrotoxicosis develops in 3% of amiodaronetreated patients. A unique underlying pathophysiology discerns one type from another, which is why early. Cardiology thyroid disease caused by amiodarone, an iodinerich antiarrhythmic, which occurs in up to 10% of amiodarone recipients living in areas of moderate iodine deficiency. Quantitative uptake of sestamibi differentiates type 1. We describe a case of amiodarone induced thyrotoxicosis ait with cardiopulmonary arrest cpa in a. Amiodarone, thyroid dysfunction, thyrotoxicosis, hypothyroidism. It was decided to admit the patient with a provisional diagnosis of amiodarone induced thyrotoxicosis. Transplacentally transferred maternal trab may stimulate neonatal tsh receptor leading to goiter and hyperthyroidism.
Amiodarone is widely used in the treatment of paroxysmal atrial tachycardia, atrial fibrillation, recurrent severe ventricular arrhythmias and maintenance of sinus rhythm following cardioversion. Thyroid abnormalities associated with treatment with lithium have been widely reported in medical literature to date. Medicine endocrinology thyroid disorders hyperthyroid. Serum interleukin6 in amiodaroneinduced thyrotoxicosis. In all forms of overt thyrotoxicosis, the serum value of tsh is decreased and the measurements of free thyroxine t4 or free thyroxine index or free triiodothyronine t3, or both, are raised. In addition, it can also cause type ii amiodarone induced thyrotoxicosis, which occurs from actual thyroid tissue destruction. Neonatal thyrotoxicosis is a rare but potentially lifethreatening condition in offsprings of mothers with graves disease and elevated tsh receptor antibodies trab during pregnancy. Diagnosis and management of thyrotoxicosis the bmj.
Since amiodarone was introduced in japan in 1992, the incidence of the drug induced thyroid dysfunction has been increasing. It is more likely to occur in regions of iodine deficiency in people with nodular goiters who are then exposed to an excess of iodine 152,153. The mortality of thyroid storm without treatment ranges from 80% to 100%. G describe the roles, responsibilities, and relationships of federal versus state public health agencies in a field investigation.
Hyperthyroidism thyrotoxicosis hyperthyroidism elevated serum levels of thyroid hormones caused by overproduction of thyroid hormones thyrotoxicosis. Central hypothyroidism may be induced by inhibition of thyroidstimulating hormone bexarotene or corticosteroids or by immunological mechanisms antictla4. Amiodaroneinduced thyroid dysfunction in clinical practice. The clinical presentation, serum thyroid function test results, and serum trab titers can help differentiate the etiology of thyrotoxicosis. Cause excess production of hormone characterized by increasing in radioactive iodine uptake. For those living in iodinedepleted areas, the incidence is higher 10%. Amiodarone induced thyrotoxicosis develops in 3% of amiodaronetreated patients. Ait presentation of a case report annelies tonnelier brigitte velkeniers 141220 herhaling titel van presentatie 1. Typically blood tests show a low thyroid stimulating hormone tsh and.
Thyrotoxicosis factitia is a rare disorder characterized by elevated levels of plasma thyroid hormones due to increased intake which can be iatrogenic, accidental, or intentional. Treatment depends on subtype and aetiology, whilst further management of the underlying. Amiodarone induced thyrotoxicosis ait occurs in both abnormal type i and apparently normal type ii thyroid glands due to iodine induced excessive thyroid hormone synthesis in patients with nodular goiter or latent graves disease type i or to a thyroiddestructive process caused by amiodarone or iodine type ii. It is usually due to an overproduction of thyroid hormones by the thyroid gland itself hyperthyroidism, but there are a variety of other conditions that may cause thyrotoxicosis other than thyroid hyperfunction. Pdf management of amiodaroneinduced thyrotoxicosis at a. Learning objectives after completing this case study, the participant should be able to. In these patients, thyroidectomy is a valid therapeutic option. G list the key tasks involved in investigating epidemics of unknown cause. Most patients with graves hyperthyroidism have a diffuse goiter, but so do patients with other, less common causes of hyperthyroidism such as painless thyroiditis and thyroidstimulating hormone tshsecreting pituitary tumors. Amiodarone, an iodinerich cardiac drug, may induce thyrotoxicosis ait, which can occur in patients with preexisting thyroid abnormalities and in subjects with apparently normal thyroid glands. Patients with thyrotoxicosis induced acute myocardial infarction ami are unusual and almost all reported cases have been associated with graves disease. Many symptoms and signs of the thyrotoxic crisis result from a concomitant sympathoadrenal hyperactivity, although the con69 abstract.
These clots may eventually become dislodged, causing embolism, stroke and other disorders. An audit of amiodarone induced thyrotoxicosis do antithyroid drugs alone provide adequate treatment. Amiodarone is an iodinebased, potent antiarrhythmic drug bearing a structural resemblance to thyroxine t4. Amiodaroneinduced thyrotoxicosis with cardiopulmonary. Neonatal thyrotoxicosis potentially lifethreatening. Amiodaroneinduced thyrotoxicosis definition of amiodarone. The mechanisms of atrial fibrillation in hyperthyroidism. Subclinical thyrotoxicosis is defined as the presence of a persistently low serum concentration of tsh, with normal free t3 and t4 concentrations. List the key tasks involved in investigating epidemics of unknown cause. A third cause of thyrotoxicosis in a newborn is the transfer of thyroidstimulating antibodies in the mothers milk.
The most common forms of hyperthyroidism include diffuse toxic goiter graves disease, toxic multinodular goiter plummer disease, and toxic adenoma. We report 3 cases of ait associated with clinical andor biochemical features consistent with thyroid damage. Atrial fibrillation af is a complex condition with several possible contributing factors. Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones. Hence, the thyrotoxicosis induced effect of amiodarone should not preclude its use in thyrotoxic atrial fibrillation, provided that it is given in conjunction with antithyroid agents. This hypothesis was supported by a painful thyroid case 1. Apr 10, 2020 hyperthyroidism is a set of disorders that involve excess synthesis and secretion of thyroid hormones by the thyroid gland, which leads to the hypermetabolic condition of thyrotoxicosis.
Two types of amiodarone induced thyrotoxicosis are recognized, designated type 1 and type 2, based on whether or not the patient had a preexisting thyroid disorder. Jun 15, 2017 clinical relevance to our knowledge, this is the first report of clinical thyrotoxicosis in a dog induced by exogenous t3, although the source of exogenous t3 was not identified. These include goitre, hypothyroidism, hyperthyroidism and autoimmune thyroiditis. Treatment of amiodaroneinduced thyrotoxicosis type 2. When prednisone fails to restore euthyroidism, possibly due to mixed cases of ait type 1 and 2, perchlorate clo 4 might be useful because clo 4 reduces the cytotoxic effect of amiodarone on thyrocytes. Patients treated with amiodarone may manifest altered thyroid hormone profile without thyroid dysfunction, or they may present with clinically significant amiodarone induced. We studied the thyroid function of patients with amiodarone induced thyrotoxicosis ait and 11 patients with amiodarone associated hypothyroidism aah who had been referred to our institute in the last 6years.
Amiodarone induced thyrotoxicosis ait occurs most frequently in patients with underlying thyroid disease and is generally believed to be due to the iodine contamination of amiodarone and iodine. Amiodarone induced thyrotoxicosis with cardiopulmonary arrest kosuke inoue 1, jun saito, tetsuo kondo2, kaoru miki3, chiho sugisawa1, yuya tsurutani1, naoki hasegawa4, shinya kowase5, yukio kakuta4, masao omura1 and tetsuo nishikawa1 abstract. Af occurs in up to 15% of patients with hyperthyroidism compared to 4% of people in the general. Amiodarone induced thyrotoxicosis can occur in either of two forms, type 1 or type 2, depending on whether there was a positive history of thyroid dysfunction prior to the use of amiodarone therapy or not, respectively. Nov 29, 2006 amiodaroneinduced thyrotoxicosis ait develops in 3% of amiodaronetreated patients in north america. Update on the diagnosis and treatment of hyperthyroidism pdf. Although most patients remain clinically euthyroid, a significant minority up to 15% of patients in the uk and the usa develop amiodarone induced hypothyroidism or thyrotoxicosis. Amiodarone induced thyrotoxicosis ait, occurring in 610% of patients managed with amiodarone 2, is the result of either accelerated thyroid hormone synthesis secondary to iodine overload in a. To determine how expert european thyroidologists assess and treat amiodarone induced thyrotoxicosis ait.
If there are components of both types, then a faint but definite uptake can be seen. On suspicion of amiodarone induced thyroid dysfunction, an urgent thyroid function test was done which revealed surprisingly hyperthyroidism. Evaluating and managing patients with thyrotoxicosis pdf. Amiodarone can lead to both hypothyroidism amiodaroneinduced hypothyroidism and less commonly hyperthyroidism amiodaroneinduced thyrotoxicosis. The aim of the present study was to show, that total thyroidectomy under general anaesthesia in patients with amiodarone induced thyrotoxicosis ait is safe without necessarily obtaining an. The japan thyroid association and japan endocrine society. Etiologies of thyrotoxicosis are diverse, one of them being caused by iodineinduced hyperthyroidism. Hyperthyroidism generally presents with nervousness, fatigue, palpitations, heat intolerance, and weight loss.588 1105 776 46 426 78 381 659 1403 49 1404 603 1037 579 1254 89 333 656 256 451 941 67 1302 994 905 1266 929 1242 1088 1246 1344 1055