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A Case of Type 2 Amiodarone-Induced Thyrotoxicosis That Underwent Total Thyroidectomy under High-Dose Steroid Administration.

Hashimoto K, Ota M, Irie T, Takata D, Nakajima T, Kaneko Y, Tanaka Y, Matsumoto S, Nakajima Y, Kurabayashi M, Oyama T, Takeyoshi I, Mori M, Yamada M - Case Rep Endocrinol (2015)

Bottom Line: Amiodarone is used commonly and effectively in the treatment of arrhythmia; however, it may cause thyrotoxicosis categorized into two types: iodine-induced hyperthyroidism (type 1 amiodarone-induced thyrotoxicosis (AIT)) and destructive thyroiditis (type 2 AIT).Even though steroid had been administered to the patient (maximum 80 mg of prednisolone), the operation was performed safely and no acute adrenal crisis as steroid withdrawal syndrome was found after the operation.Few cases of type 2 AIT that underwent total thyroidectomy with high-dose steroid administration have been reported.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan ; Department of Preemptive Medicine and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.

ABSTRACT
Amiodarone is used commonly and effectively in the treatment of arrhythmia; however, it may cause thyrotoxicosis categorized into two types: iodine-induced hyperthyroidism (type 1 amiodarone-induced thyrotoxicosis (AIT)) and destructive thyroiditis (type 2 AIT). We experienced a case of type 2 AIT, in which high-dose steroid was administered intravenously, and we finally decided to perform total thyroidectomy, resulting in a complete cure of the AIT. Even though steroid had been administered to the patient (maximum 80 mg of prednisolone), the operation was performed safely and no acute adrenal crisis as steroid withdrawal syndrome was found after the operation. Few cases of type 2 AIT that underwent total thyroidectomy with high-dose steroid administration have been reported. The current case suggests that total thyroidectomy should be taken into consideration for patients with AIT who cannot be controlled by medical treatment and even in those under high-dose steroid administration.

No MeSH data available.


Related in: MedlinePlus

(a) Gross pathological findings of the excised thyroid gland. (b, c) H-E staining of the thyroid gland in low-power (b) and high-power fields (c). Several sizes of follicle were regularly lined with flattened follicular epithelium. The lumen was filled with colloid. Scattered disrupted follicles with enlarged epithelium and cytoplasmic vacuoles were observed (b). Macrophages had infiltrated and multinucleated giant cells were found in follicular lumen (c). Immunostaining with anti-KP-1 (CD68) antibody (d). Immunostaining with antithyroglobulin antibody (e).
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fig4: (a) Gross pathological findings of the excised thyroid gland. (b, c) H-E staining of the thyroid gland in low-power (b) and high-power fields (c). Several sizes of follicle were regularly lined with flattened follicular epithelium. The lumen was filled with colloid. Scattered disrupted follicles with enlarged epithelium and cytoplasmic vacuoles were observed (b). Macrophages had infiltrated and multinucleated giant cells were found in follicular lumen (c). Immunostaining with anti-KP-1 (CD68) antibody (d). Immunostaining with antithyroglobulin antibody (e).

Mentions: A 40-year-old man suffering from dilated cardiomyopathy had been prescribed amiodarone for 2.5 years. Seven weeks before the consultation at our department, his serum-free T4 levels increased above the upper limit and thyrotoxicosis developed. His thyroid status was as shown in Figure 1. An attending cardiologist consulted at our thyroid clinic about the patient's thyrotoxicosis, but he had no complaints. He did not show any tachycardia or finger tremor, despite the thyrotoxicosis. His thyroid gland was not swollen and ultrasonic study revealed a slightly enlarged thyroid gland with almost monotonous echogenicity (Figure 2(a)). The Doppler flow rate inside the thyroid gland was not increased (Figure 2(b)). To differentiate the diagnosis of thyrotoxicosis, we planned to investigate thyroid iodine uptake. Ten days after the first visit, he showed symptoms of acute heart failure and was admitted to the intensive care unit of our hospital. His thyrotoxicosis had worsened by the time of admission, with increased levels of thyroglobulin, suggesting destructive thyroiditis (Table 1). Amiodarone administration was stopped and inorganic iodine administration (189 mg/day) was started upon admission; however, his thyrotoxicosis was prolonged and worsened. His cardiac function also worsened, with the thyrotoxicosis being exacerbated (Figure 3). On admission, his heart rate was over 180 bpm and systolic blood pressure was 220 mmHg. Oxygen saturation rate was 70% under 10 L/min of oxygen administration with a venturi mask. Intra-arterial balloon pumping was performed to maintain the circulation. On the day after admission, administration of 200 mg of hydrocortisone was started, in addition to inorganic iodine. After the hydrocortisone administration, free T3 levels were somewhat improved, but free T4 levels remained high. To control and suppress the destruction of the thyroid, 40 mg of PSL was administered instead of hydrocortisone. Subsequently, 60 mg of PSL improved the serum-free T4 levels, so we tapered the dose of PSL gradually. However, at a dose of 20 mg of PSL, the thyrotoxicosis relapsed. At this point, TSH receptor antibody (TRAb) became positive (Figure 1), so we decided to prescribe 15 mg of methimazole (MMI) together with 40 mg of PSL. Two days after these prescriptions, his free T4 levels increased to above the normal range. Thirty milligrams of MMI, 40 mg of PSL, and inorganic iodine (189 mg/day) did not suppress the destructive thyroiditis. On the 17th day of admission, thyroid 99mTc uptake was investigated, but none was observed (Figure 2(c)). At this point, we made a final diagnosis of type 2 amiodarone-induced thyrotoxicosis (AIT). On the 23rd day of admission, MMI was discontinued and the administration of 80 mg of PSL was maintained. Subsequently, we attempted to taper the dose of PSL, but under a dose of 80 mg of PSL, overt thyrotoxicosis was not controlled (Figure 1). Since over 2.5 months had passed since a high dose of PSL had been administered, we decided to perform total thyroidectomy. The administration of 80 mg of PSL was continued until the operation. With informed consent from the patient and his wife, total thyroidectomy was performed on the 78th day of admission. Intravenous administration of 40 mg of PSL and 200 mg of hydrocortisone was performed during the operation. The operation was safely performed and 25.6 g of thyroid was resected. After the operation, PSL was discontinued and the dose of hydrocortisone was carefully tapered. Two days after the thyroidectomy, hydrocortisone was tapered to 100 mg and administered orally. Then, hydrocortisone was again gradually tapered to 15 mg eleven days after the surgery. Twenty-five days after the operation, hydrocortisone was tapered to 5 mg, and it was discontinued on the forty-sixth day after the thyroidectomy. During the tapering of hydrocortisone and after its discontinuation, the patient demonstrated no symptoms of adrenal insufficiency. Pathological findings of the excised thyroid gland are as shown in Figure 4. Grossly, the lobes became firm in consistency but maintained their normal shape (Figure 4(a)). On microscopy, several sizes of follicles were regularly lined with flattened follicular epithelium. The lumen was filled with colloid. Scattered disrupted follicles with enlarged epithelium and cytoplasmic vacuoles were observed (Figure 4(b)). It is of note that macrophages had infiltrated and multinucleated giant cells were also found in the follicular lumen (Figure 4(c)). Immunostaining with anti-KP1 (CD68) and antithyroglobulin antibodies confirmed that the infiltrated cells were macrophages but not follicular cells (Figures 4(d) and 4(e)). These findings characterized by scattered follicle disruption, vacuoles in epithelial cells, and macrophage infiltration are compatible with amiodarone toxicity [10].


A Case of Type 2 Amiodarone-Induced Thyrotoxicosis That Underwent Total Thyroidectomy under High-Dose Steroid Administration.

Hashimoto K, Ota M, Irie T, Takata D, Nakajima T, Kaneko Y, Tanaka Y, Matsumoto S, Nakajima Y, Kurabayashi M, Oyama T, Takeyoshi I, Mori M, Yamada M - Case Rep Endocrinol (2015)

(a) Gross pathological findings of the excised thyroid gland. (b, c) H-E staining of the thyroid gland in low-power (b) and high-power fields (c). Several sizes of follicle were regularly lined with flattened follicular epithelium. The lumen was filled with colloid. Scattered disrupted follicles with enlarged epithelium and cytoplasmic vacuoles were observed (b). Macrophages had infiltrated and multinucleated giant cells were found in follicular lumen (c). Immunostaining with anti-KP-1 (CD68) antibody (d). Immunostaining with antithyroglobulin antibody (e).
© Copyright Policy - open-access
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4309302&req=5

fig4: (a) Gross pathological findings of the excised thyroid gland. (b, c) H-E staining of the thyroid gland in low-power (b) and high-power fields (c). Several sizes of follicle were regularly lined with flattened follicular epithelium. The lumen was filled with colloid. Scattered disrupted follicles with enlarged epithelium and cytoplasmic vacuoles were observed (b). Macrophages had infiltrated and multinucleated giant cells were found in follicular lumen (c). Immunostaining with anti-KP-1 (CD68) antibody (d). Immunostaining with antithyroglobulin antibody (e).
Mentions: A 40-year-old man suffering from dilated cardiomyopathy had been prescribed amiodarone for 2.5 years. Seven weeks before the consultation at our department, his serum-free T4 levels increased above the upper limit and thyrotoxicosis developed. His thyroid status was as shown in Figure 1. An attending cardiologist consulted at our thyroid clinic about the patient's thyrotoxicosis, but he had no complaints. He did not show any tachycardia or finger tremor, despite the thyrotoxicosis. His thyroid gland was not swollen and ultrasonic study revealed a slightly enlarged thyroid gland with almost monotonous echogenicity (Figure 2(a)). The Doppler flow rate inside the thyroid gland was not increased (Figure 2(b)). To differentiate the diagnosis of thyrotoxicosis, we planned to investigate thyroid iodine uptake. Ten days after the first visit, he showed symptoms of acute heart failure and was admitted to the intensive care unit of our hospital. His thyrotoxicosis had worsened by the time of admission, with increased levels of thyroglobulin, suggesting destructive thyroiditis (Table 1). Amiodarone administration was stopped and inorganic iodine administration (189 mg/day) was started upon admission; however, his thyrotoxicosis was prolonged and worsened. His cardiac function also worsened, with the thyrotoxicosis being exacerbated (Figure 3). On admission, his heart rate was over 180 bpm and systolic blood pressure was 220 mmHg. Oxygen saturation rate was 70% under 10 L/min of oxygen administration with a venturi mask. Intra-arterial balloon pumping was performed to maintain the circulation. On the day after admission, administration of 200 mg of hydrocortisone was started, in addition to inorganic iodine. After the hydrocortisone administration, free T3 levels were somewhat improved, but free T4 levels remained high. To control and suppress the destruction of the thyroid, 40 mg of PSL was administered instead of hydrocortisone. Subsequently, 60 mg of PSL improved the serum-free T4 levels, so we tapered the dose of PSL gradually. However, at a dose of 20 mg of PSL, the thyrotoxicosis relapsed. At this point, TSH receptor antibody (TRAb) became positive (Figure 1), so we decided to prescribe 15 mg of methimazole (MMI) together with 40 mg of PSL. Two days after these prescriptions, his free T4 levels increased to above the normal range. Thirty milligrams of MMI, 40 mg of PSL, and inorganic iodine (189 mg/day) did not suppress the destructive thyroiditis. On the 17th day of admission, thyroid 99mTc uptake was investigated, but none was observed (Figure 2(c)). At this point, we made a final diagnosis of type 2 amiodarone-induced thyrotoxicosis (AIT). On the 23rd day of admission, MMI was discontinued and the administration of 80 mg of PSL was maintained. Subsequently, we attempted to taper the dose of PSL, but under a dose of 80 mg of PSL, overt thyrotoxicosis was not controlled (Figure 1). Since over 2.5 months had passed since a high dose of PSL had been administered, we decided to perform total thyroidectomy. The administration of 80 mg of PSL was continued until the operation. With informed consent from the patient and his wife, total thyroidectomy was performed on the 78th day of admission. Intravenous administration of 40 mg of PSL and 200 mg of hydrocortisone was performed during the operation. The operation was safely performed and 25.6 g of thyroid was resected. After the operation, PSL was discontinued and the dose of hydrocortisone was carefully tapered. Two days after the thyroidectomy, hydrocortisone was tapered to 100 mg and administered orally. Then, hydrocortisone was again gradually tapered to 15 mg eleven days after the surgery. Twenty-five days after the operation, hydrocortisone was tapered to 5 mg, and it was discontinued on the forty-sixth day after the thyroidectomy. During the tapering of hydrocortisone and after its discontinuation, the patient demonstrated no symptoms of adrenal insufficiency. Pathological findings of the excised thyroid gland are as shown in Figure 4. Grossly, the lobes became firm in consistency but maintained their normal shape (Figure 4(a)). On microscopy, several sizes of follicles were regularly lined with flattened follicular epithelium. The lumen was filled with colloid. Scattered disrupted follicles with enlarged epithelium and cytoplasmic vacuoles were observed (Figure 4(b)). It is of note that macrophages had infiltrated and multinucleated giant cells were also found in the follicular lumen (Figure 4(c)). Immunostaining with anti-KP1 (CD68) and antithyroglobulin antibodies confirmed that the infiltrated cells were macrophages but not follicular cells (Figures 4(d) and 4(e)). These findings characterized by scattered follicle disruption, vacuoles in epithelial cells, and macrophage infiltration are compatible with amiodarone toxicity [10].

Bottom Line: Amiodarone is used commonly and effectively in the treatment of arrhythmia; however, it may cause thyrotoxicosis categorized into two types: iodine-induced hyperthyroidism (type 1 amiodarone-induced thyrotoxicosis (AIT)) and destructive thyroiditis (type 2 AIT).Even though steroid had been administered to the patient (maximum 80 mg of prednisolone), the operation was performed safely and no acute adrenal crisis as steroid withdrawal syndrome was found after the operation.Few cases of type 2 AIT that underwent total thyroidectomy with high-dose steroid administration have been reported.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan ; Department of Preemptive Medicine and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.

ABSTRACT
Amiodarone is used commonly and effectively in the treatment of arrhythmia; however, it may cause thyrotoxicosis categorized into two types: iodine-induced hyperthyroidism (type 1 amiodarone-induced thyrotoxicosis (AIT)) and destructive thyroiditis (type 2 AIT). We experienced a case of type 2 AIT, in which high-dose steroid was administered intravenously, and we finally decided to perform total thyroidectomy, resulting in a complete cure of the AIT. Even though steroid had been administered to the patient (maximum 80 mg of prednisolone), the operation was performed safely and no acute adrenal crisis as steroid withdrawal syndrome was found after the operation. Few cases of type 2 AIT that underwent total thyroidectomy with high-dose steroid administration have been reported. The current case suggests that total thyroidectomy should be taken into consideration for patients with AIT who cannot be controlled by medical treatment and even in those under high-dose steroid administration.

No MeSH data available.


Related in: MedlinePlus