Thyroid Storm (Thyroid Crisis)

 

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Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Chelsea Reed, Elaine Lonnemann, Lucinda hampton, Kim Jackson, WikiSysop and Adam Vallely Farrell  

Definition/Description

An acute, life-threatening exacerbation of thyrotoxiosis. This condition is rare now due to more efficient diagnosis and treatment of thyrotoxicosis in addition to improved management pre and post surgery. When it does occur, it is following illness, trauma, surgery or other major physiological stress in an individual with existing thyrotoxicity. Thyroid storm occurs most commonly in those with uncontrolled or undiagnosed thyrotoxicity without a precipitating factor. Individuals with a history of hyperthyroidism, Graves’ disease, toxic multinodular goiter, adenoma or any other cause of endogenous thyrotoxicity are at the highest risk for experiencing a thyroid storm. ^{[2] [4] [5]}

Prevalence

Rare, but high mortality rates at 10-20%.[1] Currently, incidence may be as low as 0.2 cases/100,000 population. [5] More common in women than men (10:1) [11].

Characteristics/Clinical Presentation

Classic presentation characterized by signs and symptoms of hypermetabolism including: ^{[1] [3] [5]}

• Severe tachycardia
• Elevated blood pressure
• Heart failure
• Peripheral edema
• Pulmonary edema
• Chest pain
• Hyperthermia (up to 105.3℉ or 40.7℃)
• Restlessness
• Agitation
• Delirium or psychosis
• Jaundice
• Abdominal pain
• Nausea and vomiting
• Diarrhea
• Profuse sweating
• Dehydration
• Tremor
• Coma

Central Features:^[4]

• Thyrotoxicosis
• Abnormal CNS function
• Fever
• Tachycardia (above 130bpm)
• GI tract symptoms
• Evidence of impending or present CHF

Elderly patients can have an atypical presentation characterized by: ^{[1] [5]}

• Apathy
• Stupor
• Weakness
• Cardiac failure
• Coma
• Minimal signs of thyrotoxicity
• Absent or low fever

Musculoskeletal Manifestations:
See hyperthyroidism

Associated Co-morbidities

• Hyperthyroidism
• Congestive heart failure
• Coronary artery disease
• Sjogren’s syndrome
• Rheumatoid arthritis
• Psoriatic arthritis
• Chronic periarthritis
• Myasthenia gravis ^[3]
  

Medications ^[10]

Thionamide: blocks the production/release of the thyroid hormone, as well as the conversion of T4-T3.
Types:

• Propylthiouracil (PTU)
• Methimazole(MMI)

Iodine: blocks the conversion of T4-T3.
Types:

• Saturated solution potassium iodine (SSKI)
• Lugol’s Solution

IMPORTANT: This MUST only be given 1 hour after PTU has been administered. Iodine is a substrate in the production of the thyroid hormone and could make the situation worse if given before the production has been stopped with the use of PTU.
Beta Blocker: blocks the sympathetics peripherally
Types:

• Propanolol
• Esmolol

Steroids: block the peripheral conversion of T4 to T3 and in addition boosts the hypothalamic pituitary access.
Types:

• Hydrocortisone
• Decadron
  
  

Diagnostic Tests/Lab Tests/Lab Values

Any signs of end organ dysfunction may be seen. Burch and Wartofsky suggested a scoring system to illustrate common features that can be seen when thyrotoxicosis has progressed enough to be considered a thyroid storm (Table 1). ^[1]

Table 1. Diagnostic Criteria for Thyroid Storm
**INSERT TABLE**

IF lab tests are performed TSH values with be low to undetectable and T4 will be high. ^[11]

Etiology/Causes

Thyrotoxicity occurs when there are abnormally high levels of thyroid hormone circulating within the body, most often due to overactivity of the thyroid gland. Graves’ disease is the most common form of thyrotoxicosis that leads to a thyroid storm. Other causes include multinodular goiter and toxic adenoma. The full pathophysiology of thyroid storm is unknown, but the exposure of increased numbers of beta1-adrenergic receptors to heightened catecholamine levels during times of stress is thought to play a role. Another cause is thought to be involved with the displacement of free thyroid hormones by inhibiting cytokines during illness. ^[1]

Precipitating Factors:^{[2] [3] [4]}

• Trauma
• Infection
• Surgery
• Emotional/Physiological Stress
• Diabetic Ketoacidosis
• Pregnancy
• Pulmonary Embolism
• Myocardial Infarction
• Pneumonia
• Upper respiratory tract infection
• Enteric infections
  
  

Systemic Involvement

Systemic Manifestations of Hyperthyroidism^{[1] [2] [3] [4] [5]}

• • INSERT TABLE**

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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