Abstract
BackgroundAmiodarone is a widely used antiarrythmic drug, which may produce secondary effects on the thyroid. In 14–18% of amiodarone-treated patients, there is overt thyroid dysfunction, usually in the form of amiodarone-induced thyrotoxicosis, which can be difficult to manage with standard medical treatment.Case presentationPresented is the case of a 65-year-old man, under chronic treatment of atrial fibrillation with amiodarone, who was admitted to the Intensive Care Unit with acute cardio-respiratory failure and fever. He was recently hospitalized with respiratory distress, attributed to amiodarone-induced pulmonary fibrosis. Clinical and laboratory investigation revealed thyrotoxicosis due to amiodarone treatment. He was begun on thionamide, prednisone and beta-blockers. After a short term improvement of his clinical status the patient underwent percutaneous tracheotomy due to weaning failure from mechanical ventilation, which led to the development of recurrent thyrotoxicosis, unresponsive to medical treatment. Finally, the patient developed multiple organ failure and died, seven days later.ConclusionWe suggest that percutaneous tracheotomy could precipitate a thyrotoxic crisis, particularly in non-euthyroid patients suffering from concurrent severe illness and should be performed only in parallel with emergency thyroid surgery, when indicated.
Highlights
Amiodarone is a widely used antiarrythmic drug, which may produce secondary effects on the thyroid
We report a case of a patient with pulmonary fibrosis who was treated for severe AIT in a multidisciplinary Intensive Care Unit (ICU) and developed recurrent fatal thyrotoxicosis after a percutaneous tracheotomy, which was performed due to weaning failure from mechanical ventilation
Small bilateral pleural effusions were present on the chest X-ray, whereas CT scanning of the thorax revealed a pattern of pulmonary fibrosis that was attributed to chronic amiodarone treatment, after excluding other causes with fiberoptic bronchoscopy
Summary
Urgent non-thyroid surgery can be performed in thyrotoxic patients, once euthyroidism has been restored [21]. Despite initial amelioration, thyroid function tests had never been completely normalized, so we decided to perform a percutaneous instead of an open tracheotomy, under bronchoscopic guidance, limiting surgical stress as much as possible. Despite near optimum heart rate control with beta-blockers (90–100 beats/min), and aggressive pain relief, the patient's cardiovascular status was dramatically deteriorated and serum thyroid hormone concentrations were indicative of recurrent thyrotoxic storm. We conclude that in our opinion, in the ventilator dependent patient with AIT refractory to conventional medical treatment and with a concomitant severe illness, percutaneous tracheotomy should be performed, whenever indicated, only in combination with urgent thyroidectomy
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