Life-threatening ‘thyroid storm’ successfully managed during surgery

Rare complication of amiodarone, given man to treat FA's cardiac symptoms

Lindsey Shapiro, PhD avatar

by Lindsey Shapiro, PhD |

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In-depth monitoring and prompt treatment enabled a man with Friedreich’s ataxia (FA) to successfully undergo a thyroidectomy — thyroid gland removal surgery — despite active symptoms of a life-threatening “thyroid storm” during the procedure, according a recent case report.

A thyroid storm is a medical emergency that arises when the thyroid becomes overactive. It can be a rare consequence of amiodarone, a medication sometimes used to treat the disease’s cardiac symptoms.

“We believe that early identification of the clinical picture and rapid implementation of the … treatment strategies are the key to increasing the patient’s likelihood of surviving a thyroid storm,” the scientists wrote.

The article, “Anaesthetic management of thyroid storm in a patient with Friederich’s ataxia. A case report,” was published in Revista Española de Anestesiología y Reanimación.

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Excessive thyroid hormone levels, cardiac arrhythmias mark a thyroid storm

Many FA patients experience heart involvement, including hypertrophic cardiomyopathy, in which the heart muscle becomes thickened and has a harder time pumping blood throughout the body. Patients also can have heart rhythm abnormalities, or arrhythmias.

Amiodarone is designed to prevent arrhythmias by relaxing overactive heart muscles. It is one type of anti-arrhythmic medication that can be given to FA patients who fail to respond to other cardiac treatments.

However, the medication is known to be toxic to cells in the thyroid, a gland in the neck that produces certain hormones used by the body for metabolism, growth, and other functions.

In a small number of cases, amiodarone can lead to an overactive thyroid (hyperthyroidism) that results in an excessive release of thyroid hormones, called thyrotoxicosis. For those patients, anti-thyroid medications are recommended along with stopping amiodarone’s use.

Still, some patients may experience worsening thyrotoxicity that’s accompanied by serious arrhythmias, a life-threatening emergency known as a “thyroid storm.” Those patients can require a thyroidectomy.

Scientists at a hospital in Spain reported the surgical management of a 26-year-old man with Friedreich’s ataxia who underwent a thyroidectomy due to a thyroid storm.  Disease-related cardiomyopathy was diagnosed in 2013, and he had been admitted to the hospital several times since 2018 due to cardiac complications despite treatment with amiodarone and other interventions.

While on amiodarone, the man developed significant hyperthyroidism. His doctors stopped the treatment and started him on a course of methimazole and the steroid prednisone to control thyroid activity.

A month later, the patient returned to the hospital with worsening arrhythmias that were consistent with a thyroid storm. Symptoms eased at the hospital during antithyroid treatment and his heart rate normalized, but doctors could not get his thyroid hormone levels under control.

He was scheduled for a thyroidectomy under general anesthesia. Due to the patient being at high risk for poor outcomes, he was to be intensely, and invasively, monitored for physiological changes.

Monitoring signaled a thyroid storm, and treatment began

During the surgery, doctors noted a rise in body temperature, an elevated heart rate, and low blood pressure, which “could not be attributed to anaesthesia or any specific surgical manipulation,” they wrote. Signs of fluid buildup in the lungs also were observed.

Ultimately, the doctors determined that the man was experiencing a new thyroid storm episode. They initiated supportive measures that included medications to control fever, heart rate, and blood pressure, as well as anti-thyroid medications.

“These measures allowed us to keep the patient stable enough to complete the surgery,” the scientists wrote.

The man recovered well in the hospital, continuing treatment with anti-thyroid medications during his recovery. He was discharged five days later.

Scientists noted that an in-depth monitoring of the patient during the surgery was critical for a good outcome. In doing so, it “allowed us to rapidly diagnose the early signs of thyroid storm and immediately start treatment, which, according to the literature, are essential for survival,” they concluded.