Medicina

Thyroid storm
Author
Douglas S Ross, MD
Section Editor
David S Cooper, MD
Deputy Editor
Jean E Mulder, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2012. | This topic last updated: jul 17, 2012.
INTRODUCTION — Thyroid storm is a rare, life-threatening condition characterized bysevere clinical manifestations of thyrotoxicosis [1]. In a national survey from Japan, the incidence of thyroid storm in hospitalized patients was 0.20 per 100,000 per year [2]. Although thyroid storm can develop in patients with long-standing untreated hyperthyroidism (Graves’ disease, toxic multinodular goiter, solitary toxic adenoma), it is often precipitated by an acute event such as thyroid ornonthyroidal surgery, trauma, infection, an acute iodine load, or parturition. The advent of appropriate preoperative preparation of patients undergoing thyroidectomy for hyperthyroidism has led to a dramatic reduction in the prevalence of surgically-induced thyroid storm. Several other factors may lead to hospitalization of patients with severe thyrotoxicosis, including co-morbid conditions, poorcompliance with specific therapy, and low socioeconomic status [3].
It is unclear why certain factors result in the development of thyroid storm. Hypotheses include a rapid rate of increase in serum thyroid hormone levels, increased responsiveness to catecholamines, or enhanced cellular responses to thyroid hormone [1]. The degree of thyroid hormone excess (elevation of T4 and T3, suppression ofTSH) typically is not more profound than that seen in patients with uncomplicated thyrotoxicosis. However, one study found that while the total T4 and T3 levels were similar to those seen in uncomplicated patients, the free T4 and free T3 concentrations were higher in patients with thyroid storm [4].
The diagnosis and management of thyroid storm will be reviewed here. The clinical manifestations,diagnosis, and treatment of hyperthyroidism are reviewed separately. (See "Overview of the clinical manifestations of hyperthyroidism in adults" and "Diagnosis of hyperthyroidism" and "Treatment of Graves' hyperthyroidism" and "Thionamides in the treatment of Graves' disease" and "Surgery in the treatment of hyperthyroidism: Indications, preoperative preparation, and postoperative follow-up".)DIAGNOSIS — The diagnosis of thyroid storm is based upon clinical findings. Patients with severe and life-threatening thyrotoxicosis typically have an exaggeration of the usual symptoms of hyperthyroidism. Cardiovascular symptoms in many patients include tachycardia to rates that can exceed 140 beats/minute and congestive heart failure. Hypotension, cardiac arrhythmia, and death from cardiovascularcollapse may occur [5]. Hyperpyrexia to 104 to 106ºF is common. Agitation, anxiety, delirium, psychosis, stupor, or coma are also common and are considered by many to be essential to the diagnosis. Severe nausea, vomiting, diarrhea, abdominal pain, or hepatic failure with jaundice can also occur. Physical examination may reveal goiter, ophthalmopathy (in the presence of Graves’ disease), lid lag,hand tremor, and warm and moist skin. (See "Overview of the clinical manifestations of hyperthyroidism in adults".)
There are no universally accepted criteria or validated clinical tools for diagnosing thyroid storm. In 1993, Burch and Wartofsky introduced a scoring system using precise clinical criteria for the identification of thyroid storm (table 1) [6]. A score of 45 or more is highlysuggestive of thyroid storm, whereas a score below 25 makes thyroid storm unlikely. A score of 25 to 44 is suggestive of impending storm. While this scoring system is likely sensitive, it is not very specific. Other diagnostic criteria based upon similar clinical findings (central nervous system manifestations, fever, tachycardia, congestive heart failure, gastrointestinal manifestations) have been...