甲亢危象的识别与处理实践

Differential diagnosis and treatment of thyroid storm

甲亢危象是一种罕见的、危及生命的内分泌急症,患者有严重的甲状腺毒症临床表现。美国和日本的研究显示,甲亢危象的年发病率分别为(0.57~0.76)/10万和0.2/10万。甲亢危象占甲状腺毒症患者的0.22%,占住院甲状腺毒症患者的5.4%。即使在获得及时治疗的情况下,甲亢危象患者的死亡率仍高达10%~30%;若未治疗,则患者的死亡率可达90%。甲亢危象的急诊漏诊和误诊率高达43.48%。导致甲亢危象的诱因可能包括突然停用抗甲状腺药物或急性事件(如感染、创伤、甲状腺或非甲状腺手术、急性碘负荷或分娩)以及其他少见的病因。目前尚无公认的标准或临床工具用于诊断甲亢危象,其诊断依据包括存在甲亢的生化证据(游离T4或T3升高、TSH降低),以及危及生命的严重症状(高热、心血管功能障碍及精神状态改变等)。伯奇-沃托斯基点量表(Burch-Wartofsky point scale,BWPS)近30年来一直被广泛应用于甲亢危象的诊断。甲亢危象的主要治疗包括一般对症治疗及针对甲状腺的特异性治疗,包括去除诱因和治疗并发症,如使用抗甲状腺药物、碘剂、糖皮质激素及β受体阻滞剂等抑制甲状腺激素合成,或阻断外周T4向T3转换或抑制甲状腺激素释放,对上述治疗后病情改善不明显者,则可以尝试血液净化(血浆置换)治疗。此外,支持治疗对于甲亢危象患者亦至关重要。甲亢危象患者经过积极治疗,病情多在1~2d内改善。甲亢危象抢救成功后,应采用根治方法治疗甲亢。

Thyroid storm is a rare,life-threatening endocrine emergency characterized by severe clinical manifesta-tions of thyrotoxicosis.Studies in the United States and Japan show that the annual incidence rates of hyperthyroid storm are(0.57-0.76)per 100000 people and 0.2/100000 people,respectively,accounting for 0.22%of all hyperthyroid patients and 5.4%of hospitalized hyperthyroid patients.Even with timely treatment,the mortality rate of patients with hyperthyroid-ism storm is still as high as 10%-30%;If left untreated,the mortality rate of patients may reach 90%.The misdiagnosis and missed diagnosis rate of hyperthyroidism storm in the Emergency Department is as high as 43.48%.It may be precipitated by abrupt discontinuation of antithyroid drugs or by an acute event such as infection,trauma,thyroid or nonthyroidal sur-gery,an acute iodine load,or parturition and other rare causes.There are currently no recognized standards or validated clinical tools for diagnosing thyroid storm.The diagnosis of thyroid storm is based upon the presence of biochemical evi-dence of hyperthyroidism(elevation of free T4 and/or T3 and suppression of TSH),and severe and life-threatening symptoms(hyperpyrexia,cardiovascular dysfunction,and altered mentation).BWPS has been widely used for the identification of thy-roid storm for nearly 30 years.The main treatments for thyroid storm consist of symptomatic treatment and specific treat-ment for the thyroid gland,including removing the cause and treating complications cuse of thionamide,iodine,glucocorti-coids and beta-blockers to inhibit new hormone synthesis,block the peripheral conversion of T4 to T3,inhibition of the re-lease of thyroid hormone.If the above treatment do not improve the condition,blood purification therapy(plasmapheresis)can be tried.In addition to specific therapy directed against the thyroid,supportive therapy is essential.After active treat-ment,most of the status of patients with thyroid storm are improved within 1 to 2 days.After a successful rescue of thyroid storm,hyperthyroidism should be treated by radical treatment.