Thyroid crisis : Six years experience at Prapokklao Hospital.

Abstract

Background : Thyroid crisis is life-threatening syndrome. The thyroid crisis is much less common today than in the past, and it accounts for no more than 1-2 percent of hospital admissions for thyrotoxicosis in general. The incidence of thyroid crisis at Prapokklao Hospital in 2004 was about 5 percent, it is seem be high.So the review of thyroid crisis should be done to evaluate the accuracy of diagnosis, treatment including to find out mortality rate and how to predict.

Method : Descriptive retrospective study. All in-patient medical records of thyroid crisis during October 1999 to October 2004 were reviewed and evaluated thyroid crisis Burch and Wartofskyû score including APACHE II score. Correlation of any factors and mortality rate was tested by Mann-Whitney U test. Out-patient medical records reviewing and other means were done for search about the definitive treatment of hyperthyroidism and results after discharge.

Results : The reports of thyroid crisis were 21 cases. The incidence of thyroid crisis during first 3 years was 1.5 percent and increase to 4.6 percent in the last 3 years. Surprising 33.3 percent of patients were newly diagnosis of hyperthyroidism at the same time of thyroid crisis. The mean age was 49 years and 57 percent of patients were women. All patients could be diagnosis of thyroid crisis by Burch and Wartofskyû score (criteria for diagnosis thyroid crisis if the score more than 45 points) by the means of score are 82 points.The clinical features were 47.6 percent of COMA, 28.6 percent of congestive heart failure, 85.7 percent of atrial fibrillation and 66.7 percent of unexplained jaundice. The main of precipitating factor were infection, others were largeembolization, surgery, myocardial infarction and poor compliance. The means of free tri-iodothyronine(FT3) were 11.59 pg/ml (normal range 2.57-4.43),free thyroxine(FT4) were 4.74 pg/dl (normal range 1.01-1.79) and all thyroid stimulating hormone(TSH) were below than 0.05 IU/ml. The incidence of T4 toxicosis was 16.7 percent. Mean serum albumin was 2.42 mg/dl and 35.7 percent of patients had hypercalcemia. One case had pancytopenia. Mortality rate was 38 percent. It was correlated to APACHE II score but not correlated to thyroid crisis score and the level of thyroid hormones. Mean APACHE II score was 18 points. In general the predictive mortality rate when APACHE II score more than 25 points is about 50 percent but in this study all patients who had score more than 25 points were dead. After discharge 53.8 percent of patients still were hyperthyroidism and three patients lost to be follow up. Only 15.4 percent of survival patients had
definitive treatment of hyperthyroidism (surgery and radioactive iodine).

Conclusion : Thyroid crisis is not really rare so we should be alert to early diagnosis and treatment.