Case report
Anaesthetic management of thyroid storm in a patient with Friederich’s ataxia. A case report
Manejo anestésico de una tormenta tiroidea en un paciente afecto de ataxia de Friederich. A propósito de un caso
M. Sneyers Closa
, A. Pérez Requena, S. Sánchez García, J. Sistac Ballarín
Corresponding author
Servicio Anestesiología, Reanimación y Terapéutica del Dolor del Hospital Universitari Arnau de Vilanova, Lleida, Spain
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A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "362" "paginaFinal" => "365" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Sneyers Closa, A. Pérez Requena, S. Sánchez García, J. Sistac Ballarín" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Sneyers Closa" "email" => array:1 [ 0 => "msc9319@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pérez Requena" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Sánchez García" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Sistac Ballarín" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Anestesiología, Reanimación y Terapéutica del Dolor del Hospital Universitari Arnau de Vilanova, Lleida, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo anestésico de una tormenta tiroidea en un paciente afecto de ataxia de Friederich. A propósito de un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Friedreich's ataxia (FA) is an autosomal recessive disease that affects the corticospinal and pyramidal tracts. It has a prevalence of 2−4:100,000 population. FA is a neurodegenerative disorder characterized by the appearance of ataxia, dysarthria, oculomotor dysfunction, kyphoscoliosis, muscle weakness, and spasticity. It can also involve the heart, with hypertrophic cardiomyopathy, sometime with conduction abnormalities, being the most frequent alteration. Half of all patients with FA may present supraventricular and ventricular arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Amiodarone is a class III antiarrhythmic drug with a half-life of up to 100 days that is indicated for the management of supraventricular and ventricular arrhythmias refractory to other treatments.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the thyroid, amiodarone inhibits conversion of T4 to T3. Given its high iodine content, amiodarone has a toxic effect on thyroid epithelial cells, and in 3% of cases this can lead to hyperthyroidism or thyrotoxicosis (usually prevalent in iodine-deficient regions).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Amiodarone-induced thyrotoxicosis is classified as type I or type 2: Type 1 occurs in patients with pre-existing thyroid disease and causes hyperthyroidism secondary to increased production and release of thyroid hormone; type II occurs in patients with no thyroid dysfunction. Amiodarone-induced thyroiditis causes follicular disruption and leads to the release of thyroid hormones.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In these circumstances, amiodarone should be discontinued and treatment with antithyroid drugs and corticosteroids started. Discontinuing amiodarone can occasionally worsen thyrotoxicity and cause serious arrhythmias. Total thyroidectomy should be considered in patients that are refractory to antithyroid drugs.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We report the case of a patient with FA undergoing total thyroidectomy due to failure of medical management of hyperthyroidism secondary to amiodarone-induced thyrotoxicosis, who presented intraoperative thyroid storm.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">Our patient was a 26-year-old man, allergic to cephalosporins, with a history of FA with structural cardiac involvement (non-obstructive hypertrophic cardiomyopathy) diagnosed in 2013. Since 2018, he had been admitted several times due to decompensation secondary to atrial fibrillation/atrial flutter (AFib/AFL) with rapid ventricular response and impaired ventricular function despite treatment with amiodarone and several electrical cardioversion (ECV) procedures.</p><p id="par0035" class="elsevierStylePara elsevierViewall">He developed significant hyperthyroidism while taking amiodarone, so the drug was discontinued and methimazole (15 mg/8 h) and prednisone (60 mg/24 h) were started. One month later, he consulted for a new episode of AFL with 2:1 conduction that persisted despite 2 ECVs and more than 36 h of beta-blocker treatment (propranolol 0.1 mg/kg) and digoxin (1 mg/24 h) to slow the heart rate. The symptoms were consistent with a thyroid storm, so it was decided to start antithyroid treatment and plasmapheresis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Symptoms improved during his hospital stay, and the treatment administered normalised his heart rate to 80–100 bpm. Despite this improvement, it was impossible to normalise his thyroid hormones levels (TSH* < 0.01, T4l* 46.1; T3l* 6.07) despite high-dose antithyroid drugs (propylthiouracil 150 mg/8 h, Lugol's solution 5% 5 drops/6 h) and corticosteroids (prednisone 60 mg/24 h), so he was scheduled for surgery.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Preoperative blood tests were only remarkable for abnormal thyroid function (T4 48.7, T3 6.91). ECG: AFib at 103 bpm. The echocardiogram showed concentric hypertrophic cardiomyopathy with moderate-to-severe systolic dysfunction due to global hypocontractility. Severe left atrial dilatation. Moderate central functional MR. Mild PHT. EF 30%–32%.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We decided to perform total intravenous anaesthesia (TIVA). The patient was pre-medicated with 40 mg IV pantoprazole, 240 mg IV hydrocortisone and 1 mg IV midazolam. Prior to induction, awake left radial artery cannulation was performed for in-depth haemodynamic monitoring. The patient was preoxygenated for 5 min with 100% FiO2, and IV induction was performed with 16 mg etomidate, 100 mcg fentanyl, and 30 mg rocuronium. A Glidescope was used for intubation, which was uneventful. Following this, an oesophageal temperature sensor and a nasogastric (NG) tube were placed. TIVA was maintained with propofol (6−8 mg/kg/h) and remifentanil (0.05−0.15 mcg/kg/min) monitored with bispectral index (BIS) and TOF (train-of-four).</p><p id="par0055" class="elsevierStylePara elsevierViewall">All the patient's vital signs remained stable and similar to baseline for the first 100 min of the intervention, except for fluctuations in BIS: BIS 35–55; temperature 36.3–36.7°; HR 90–100 bpm; SAP 100–120, DAP 55–75; SpO2 98%–100%. Approximately 100 min after anaesthesia induction we observed a gradual increase in body temperature (reaching a peak of 38.7 °C) accompanied by an increase in heart rate (AFib with rapid ventricular response of about 140 bpm) and moderate hypotension (minimum blood pressure: 74/30). These changes could not be attributed to anaesthesia or any specific surgical manipulation. Lung auscultation revealed bibasal crackles, absent prior to surgery. After calculating the Burch-Wartofsky Point Scale score (65), we concluded that this was a new episode of thyroid storm, and started support measures: temperature control (cold compresses, 1 g IV paracetamol) and heart rate control (IV bolus of 30 mg esmolol + continuous infusion 0.3 mg/kg/min). We also administered IV boluses of phenylephrine as required (total dose: 350 mcg). Antithyroid drugs (propylthiouracil 250 mg and thiamazole 30 mg) were administered via the NG tube. These measures allowed us to keep the patient stable enough to complete the surgery. At the end of the intervention, we decided not to extubate the patient, and he was transferred to the postoperative critical care unit (PCCU) for monitoring. In the PCCU, his postoperative evolution was good, and he was extubated 4 h after the end of the surgery. Continuous infusion of esmolol was gradually decreased until it could be withdrawn prior to extubation. Antithyroid treatment with propylthiouracil 250 mg/6 h and thiamazole 30 mg/6 h, via the NG tube was maintained. No new events were observed during his stay in the PCCU, and he was discharged to the ward 24 h after surgery. The NG tube was removed on the ward, but the oral antithyroid treatment initiated in the PCCU was maintained (propylthiouracil 250 mg/6 h PO and thiamazole 30 mg/6 h PO). No new episodes of instability were observed during his stay on the ward. The patient was discharged 5 days later, and scheduled for a follow-up visit in the Endocrinology and Cardiology outpatient departments 1 month later.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">In this patient, the challenges and potential complications (thyroid storm) involved in the perioperative management of a hyperthyroid patient were further complicated by the patient’s high baseline morbidity.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Ideally, prior to surgery, patients should be in a euthyroid state in order to reduce the probability of thyroid storm, and with it, the risk of perioperative complications.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Thyroid storm is an endocrinological emergency associated with high morbidity and mortality. Early diagnosis and treatment are vital to improve survival,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> but diagnosis is often difficult, so various scales have been developed to help in this task. The best known is the Burch-Wartofsky Point Scale (BWPS) (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>),<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> that not only takes into account the dysfunction of several organs (thermoregulatory dysfunction, tachycardia, altered mental state, presence of congestive heart failure, gastrointestinal and/or hepatic dysfunction), but also rates the severity of the decompensation and the possible precipitating factors.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to perioperative management, there is no clear guidance in the literature on the choice between general anaesthesia or locoregional anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In our patient, we opted for general anaesthesia in the belief that it would guarantee greater haemodynamic stability and greater control of haemodynamic factors.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> Therefore, in addition to basic monitoring, we also performed invasive radial artery blood pressure monitoring, BIS and TOFF monitoring, and monitored temperature with an oesophageal probe. This in-depth monitoring allowed us to rapidly diagnose the early signs of thyroid storm and immediately start treatment, which, according to the literature, are essential for survival.</p><p id="par0075" class="elsevierStylePara elsevierViewall">According to existing guidelines, management of thyroid storm is based on 5 strategies.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The first is to treat the symptoms, including hyperthermia, with paracetamol and not NSAIDs, since these are thought to increase T3 levels by interfering with the binding of T3 to serum carrier proteins. We administered 1 g IV paracetamol and applied physical measures (cold compresses) to control temperature. The second strategy involves treating the cardiovascular, neurological and/or hepatic alterations. Our patient only presented cardiovascular alterations, in the form of atrial fibrillation with rapid ventricular response (HR 140 bpm), leading to haemodynamic instability (BP 74/30). Guidelines recommend the use of beta-blockers, preferably B1-selective, short-acting drugs (esmolol, as in our case, or landoliol) for heart rate control. For blood pressure control, non-catecholamine sympathomimetic agonists such as phenylephrine are recommended, since hyperthyroidism patients are thought to have increased sensitivity to catecholamines. For this reason, as soon as symptoms appeared we administered several boluses of phenylephrine (a total of 350 mcg IV) combined with continuous infusion of esmolol (0.3 mg/kg/min).</p><p id="par0085" class="elsevierStylePara elsevierViewall">The third strategy is to treat thyrotoxicosis, which is our case was achieved with propylthiouracil (250 mg via NG tube) and thiamazole (30 mg via NG tube). Both these antithyroid drugs reduce thyroid hormone synthesis, but propylthiouracil should be the first choice because it acts on both the thyroid gland and other peripheral organs, and is therefore believed to reduce T3 levels more rapidly. The fourth strategy consists of avoiding triggering stimuli, while the fifth is definitive treatment (thyroidectomy), which is beyond the remit of the anaesthesiologist.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We believe that early identification of the clinical picture and rapid implementation of the 5 treatment strategies are the key to increasing the patient’s likelihood of surviving a thyroid storm.</p><p id="par0095" class="elsevierStylePara elsevierViewall">This is why both close monitoring and skills in the use of scales such as the BWPS will allow the anaesthesiologist to rapidly diagnose the early signs of a thyroid storm, even in the presence of diffuse symptoms.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding treatment, temperature control and haemodynamic management were effective management strategies. Although antithyroid drugs were not immediately effective in resolving the symptoms, they were useful in achieving a good postoperative evolution. However, the most effective measure was completion of the intervention, as this ensured that patient was no longer exposed to possible triggering stimuli.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1999497" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1713683" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1999496" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1713684" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-11-15" "fechaAceptado" => "2022-06-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1713683" "palabras" => array:5 [ 0 => "Thyrotoxicosis" 1 => "Amiodarone" 2 => "Thyroid storm" 3 => "Friederich's Ataxia" 4 => "Anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1713684" "palabras" => array:5 [ 0 => "Tirotoxicosis" 1 => "Amiodarona" 2 => "Tormenta tiroidea" 3 => "Ataxia de Friederich" 4 => "Anestesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 26-year-old patient with Friederich's ataxia with hypertrophic obstructive cardiomyopathy undergoing total thyroidectomy due to persistent amiodarone-induced thyrotoxicosis (despite high doses of antithyroid drugs and corticosteroids), presented an intraoperative episode suggestive of thyroid storm.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thyroid storm is an endocrine emergency that is associated with high morbidity and mortality. Early diagnosis and treatment, which is of vital importance to improve survival, includes symptomatic treatment, treatment of cardiovascular, neurological, and/or hepatic manifestations and thyrotoxicosis, measures to suppress or avoid triggering stimuli, and definitive treatment.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Paciente de 26 años afecto de ataxia de Friederich con una miocardiopatía hipertrófica obstructiva sometido a una tiroidectomía total por tirotoxicosis secundaria a amiodarona persistente (a pesar de elevadas dosis de antitiroideos y corticoides) que intraoperatoriamente presentó un episodio sugestivo de tormenta tiroidea.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La tormenta tiroidea es una emergencia endocrinológica que asocia una elevada morbimortalidad. Para mejorar la supervivencia es de vital importancia un diagnóstico y tratamiento precoz que incluya: un tratamiento sintomático; el tratamiento de las manifestaciones cardiovasculares, neurológicas y/o hepáticas y de la tirotoxicosis; y así como suprimir o evitar estímulos desencadenantes y practicar un tratamiento definitivo.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Thermoregulatory dysfunction (Temperature °C)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- 37.2−37.7</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- 37.8−38.3</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- 38.4−38.8</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- 38.9−39.3</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- 39.4−39.9</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Cardiovascular</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tachycardia</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- 90−109 bpm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- 110−119 bpm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- 120−129 bpm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- 130−139 bpm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- >140 bpm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Atrial fibrillation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Absent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Congestive heart failure</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Absent</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Mild</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Moderate</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Severe</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Gastrointestinal/hepatic dysfunction</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Absent</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Moderate (diarrhoea, abdominal pain, nausea/vomiting)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Severe (jaundice)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Central nervous system disturbance</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Absent</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Mild (agitation)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Moderate (delirium, psychosis, lethargy)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Severe (seizures, coma)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Precipitant history</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Absent</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">- Present</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3319988.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Burch–Wartofsky Point Scale (BWPS).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Friedreich ataxia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. 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