JHN CQ 150525 福知山...

clinical question2015525J Hospitalist Network

/

ADL81

;

3ER

;BP162/66mmHg HR124/min,irregular RR31/min BT37.4 SpO2 95%(room air);slow pitting edemaX;;TSH

hANP110002000ml

3

JCS:100;37.8 HR(ECG)110130/min SpO2:94(02 3L/min)

;BUNCT/MRI;;35961

(TSH)1228 IU/ml 22.3 IU/ml 400

Alcohol:Insulin:Uremia:Electrolyte/Endocrine/Encephalopathy:OxygenOverdose:TemperatureTrauma:Infection:Psychiatric:Seizure,Stroke:

??

Clinical Question

(Thyrotoxic storm or crisis)

(T3T4

1. 2. 38 3. 130 / 4. 5.

a+ b 3

a b a b

2(2012)

http://square.umin.ac.jp/endocrine/rinsho_juyo/pdf/koujosen01.pdf

()()()()

Japan Coma Scale (JCS)1Glasgow Coma Scale (GCS)14

New York Heart Association (NYHA) 4 Killip III

> 3mg/dl

(apathetic thyroid storm)

http://square.umin.ac.jp/endocrine/rinsho_juyo/pdf/koujosen01.pdf

2(2012)

//

ICU

T4T3T4T3T3 or T3 Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006; 35:663.

??

Clinical Question

UpToDateThyroid storm

-blocker; Thionamide; ; ();T4T3 ;T4T3

;

Volumevolume overload

T4T3

()

()

-blocker; 6080mg46 ()

;PTU 200mg 4 or 30mg 6 criteriaPTUT4T3

;1()(saturated soluFon of potassium iodide:SSKI)56108down regulation(Wolff-Chaikoff effect)2(escape)

100mg84g6


-blocker;6080mg46 ()*-blocker(COPDPAD);0.51mg1012mg10

;-blocker loading dose250500 mcg/kg50100 mcg/kg/min

;-blocker

Ca(); -blockerrate control


thionamides()1 12

PTU;200mg 4 or ; 20mg 46or thionamidesICUPTU

PTUT4T3PTUT3

PTUT3 ICUPTU


thionamides()2 thionamide

or

PTUvsfree T3bio availability


thionamides()3 thionamidespH0.22m

PTU(pH 9.25)

PTU576mg/(50mg/mL)


-blocker;() 60mg

;() 30mg

; 200mg4

;100mg8

() 3000mg

fT4TSH4 TSH 8750mg/()10

6090120mg/ 1910

??

Clinical Question

1966Lord Brain40

Brain L,et al. Hashimotos disease and encephalopathyLancet 1966;ii:512-14.

1988

19915Hashimotos encephalopathy()

Behan PO,et al:Recurrent active disseminated encephalomyelitis isassociation with Hashimotos thyroiditisLn:Trend in EuropeanMultiple Sclerosis Research(ed by Confavreux C,et al), p161-171 Elsevier,Amsterdam,1988.

Shaw PJ,et al:Hashimotos encephalopathy:a steroidresponsive disorder associated with high anti-thyroid antibody titersreport of 5 cases. Neurology 41:228233,1991

/

UpToDateHashimoto encephalopathy

2006121

2.1/10

4144(978)

:1:4

Ferracci F, Carnevale A. The neurological disorder associated with thyroid autoimmunity. J Neurol 2006; 253:975.

Ferracci F, BerFato G, MoreRo G. Hashimoto's encephalopathy: epidemiologic data and pathogeneFc consideraFons. J Neurol Sci 2004; 217:165.


2

1);25%

2);


1) 2)

(2/3)

(12%)

(38%) *

(85%)

Psychosis()(2536%)UpToDateHashimoto encephalopathy

;-

3


(TPOAb) and/or (TgAb)-/

TPOAb TgAb220%

(CSF)


; 2335%

; 1720%

;7%

;


Ferracci F, Carnevale A. The neurological disorder associated with thyroid autoimmunity. J Neurol 2006; 253:975.

80%

(48298mg/dL)75%100mg/dL(20%)

(8169);1025%

14-3-3(CJD)


9098%

(FIRDA)


MRIT21/2MRI

or

T2


()

SPECT//

CRPESR;

;12/20


N(NH2-terminal of alpha-enolase:NAE)

2005NAE

NAECJD

)(SLE)

71520135

N(NH2-terminal of alpha-enolase:NAE)

NAE9150NAE

NAE

NAE

()10NAE

71520135

CJDADEM()(Lewy)StrokeTIAor


;(TPOAb)or(TgAb)++

//

;MRI(Gd)(+ABGVitB12)


;

14-3-3+

NAE


50mg150mg(9098%)2


;(14-3-3)MRI(?)NAE(50)

100mg3/450mg/

NAE()

Take Home Message

JHN CQ 150525 福知山...

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