Nicknamed the “butterfly gland” due to its shape, the thyroid’s impact on the body is far reaching. Usually associated with growth and metabolism, recent studies published in The Journal of Clinical Endocrinology & Metabolism – Case Reports show how thyroid dysfunction can impact the heart.
The common phrase “heart in my throat” usually refers to a feeling of anxiety, excitement, expectation, or anticipation. It can even mean that the person undergoing this sensation is experiencing a sudden amount of stress as the carotid vein in the neck is suddenly throbbing.
Recent cases in JCEM Case Reports (JCEM CR) actually take this age-old phrase to, well, heart, as they take a closer look at the thyroid – or, in two patients, the parathyroid – in studies that examine how a dysfunction in the “butterfly gland” can have a surprising and sometimes frightening impact on the heart.
Here, we summarize those cases, as endocrinologists should be aware of this connection.
Weathering a Thyroid Storm
In “Severely Dilated Cardiomyopathy and Cardiogenic Shock in a Patient with Thyroid Storm,” the authors, Mehdia Amini, MD; Jessica Liebich, MD; and Guoyu Ling, MD, of St. Louis University present the case of a 39-year-old patient with thyroid storm complicated by cardiogenic shock and severe dilated cardiomyopathy (DCM), an exceedingly rare manifestation of thyroid storm.
The patient was admitted to the hospital after someone witnessed her going into ventricular fibrillation arrest. She has a history of hypothyroidism and asthma. The EMTs got her blood flowing again, but when she was admitted, she was unresponsive, intubated, and in cardiogenic shock. She had acute kidney shock, liver shock, severe metabolic acidosis, and a severely dilated heart. She had a fever of almost 103 degrees Fahrenheit.
The endocrinology team were brought in because there was a concern of thyroid storm. The patient’s family informed the team that the patient had been previously diagnosed with Graves’ disease, but she was not adherent to medical therapy. The patient lived by herself, and the authors write that in the weeks leading up to her admission she had experienced insomnia, heat intolerance, diarrhea, weight loss, and proptosis.
“More recently,” the authors continue, “she developed shortness of breath, orthopnea, and lower-extremity edema. She had no prior history of cardiac disease or arrhythmia. Her mental status was reported to be intact at baseline.”
A thyroid test confirmed Graves’ disease. The patient was started on 20 mg of methimazole every six hours, 100 mg of intravenous hydrocortisone every eight hours, and 4 g of cholestyramine every six hours. The authors note that beta-blockers weren’t used as they are contraindicated in cardiogenic shock due to their negative inotropic and chronotropic effects, which can further impair cardiac output and exacerbate hemodynamic instability.
“Thyrotoxicosis can lead to significant cardiac dysfunction, but timely intervention can reverse myocardial damage and improve outcomes. This report emphasizes the need for individualized treatment approaches, especially in cases complicated by coexisting conditions such as hepatic dysfunction.” — Mehdia Amini, MD; Jessica Liebich, MD; and Guoyu Ling, MD, St. Louis University, St. Louis, Mo., in “Severely Dilated Cardiomyopathy and Cardiogenic Shock in a Patient with Thyroid Storm”
The patient showed significant clinical improvement over the following days. At the time of discharge, however, she showed signs of encephalopathy, but those symptoms had resolved on follow-up.
What makes this case especially complicated was that the DCM was induced by thyrotoxicosis, since thyrotoxicosis exerts profound effects on cardiac function through T3-mediated mechanisms, according to the authors.
“This case highlights the rare occurrence of DCM secondary to thyroid storm, underscoring the importance of early recognition and treatment,” the authors write. “Thyrotoxicosis can lead to significant cardiac dysfunction, but timely intervention can reverse myocardial damage and improve outcomes. This report emphasizes the need for individualized treatment approaches, especially in cases complicated by coexisting conditions such as hepatic dysfunction.”
Navigating Two Cases of Parathyroid Tumor Crises
For another study, “Dialysis for Parathyroid Tumor Crises to Combat Ventricular Arrhythmia Risk: A Report of Two Cases,” Qi Yang Damien Qi, MD; Joanna Y. Gong, MBBS; Michelle So, PhD; Christopher J. Yates, MBBS, PhD, FRACP; and Spiros Fourlanos, MBBS, FRACP, PhD – all affiliated with Royal Melbourne Hospital in Melbourne, Victoria, Australia – present two cases of severe hypercalcemia secondary to parathyroid tumors managed with dialysis prior to definitive surgery.
The first case involves a 41-year-old man who presented with three days of lower abdominal pain and constipation, as well as arthralgias of the knee and ankle. The authors write that there were no neurological or urinary symptoms. A goiter with a large, hard, left-sided irregular mass was palpable. There was no family history of endocrine tumors.
He was found to have severe hypercalcemia and parathyroid carcinoma, complicated by ventricular arrhythmias requiring cardioversion. Despite aggressive medical therapy with intravenous therapy with 0.9% saline and subcutaneous salmon calcitonin (100 IUs) every six hours, dialysis was initiated, but persistent arrhythmias necessitated emergency surgery – a left hemithyroidectomy and parathyroidectomy.
In the second case, a 30-year-woman presented with two weeks of nausea, vomiting, dizziness, fatigue, and significant muscular cramps involving both lower limbs. Neck examination revealed a large palpable neck mass, according to the authors. This patient also had no family history of endocrine tumors. “Neck imaging identified a large cystic mass abutting the inferior aspect of the right thyroid gland, with associated retrosternal extension, measuring 5.7 cm in size,” the authors write.
“These cases of parathyroid tumor crises, although rare, highlight the need for rapid intervention with treatments such as dialysis and expediting to parathyroidectomy to prevent life-threatening cardiac complications. With the increasing availability of dialysis and experience to support its use in this context, its prompt utilization should be considered for managing parathyroid crises.” — Qi Yang Damien Qi, MD; Joanna Y. Gong, MBBS; Michelle So, PhD; Christopher J. Yates, MBBS, PhD, FRACP; and Spiros Fourlanos, MBBS, FRACP, PhD, Royal Melbourne Hospital, Melbourne, Victoria, Australia, in “Dialysis for Parathyroid Tumor Crises to Combat Ventricular Arrhythmia Risk: A Report of Two Cases”
This patient was also treated aggressively with IV fluids with 0.9% saline, 100 IUs subcutaneously of salmon calcitonin every eight hours, and intravenous administration of 60 mg of pamidronate. Her hypercalcemia persisted, so she also required dialysis. She was stabilized but required definitive parathyroidectomy.
The surgeries were successful in both patients, with serum calcium normalizing. “Calcium plays a critical role in cardiac conduction, such that disorders of calcium homeostasis can cause arrhythmias,” the authors write. “Management of the parathyroid crisis must involve multiple simultaneous investigative and management strategies.”
The authors point out that these cases highlight the critical role of dialysis in stabilizing severe hypercalcemia prior to surgical intervention, particularly when arrhythmia risk is of concern. Given the possibility of cardiac complications, early consideration of dialysis should be considered in the management of parathyroid crisis, they write.
“These cases of parathyroid tumor crises, although rare, highlight the need for rapid intervention with treatments such as dialysis and expediting to parathyroidectomy to prevent life-threatening cardiac complications,” the authors conclude.” With the increasing availability of dialysis and experience to support its use in this context, its prompt utilization should be considered for managing parathyroid crises.”
Bagley is the senior editor of Endocrine News. In the December issue, he wrote about how Endocrine Society journals work to maintain the highest integrity possible.
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