Thyrotoxicosis and Thyroid Storm
Bindu Nayak, MDa, Kenneth Burman, MDa,b,c,*
Department of Endocrinology, Georgetown University Hospital, 4000 Reservoir Road NW, Building D, Suite 232, Washington, DC 20007, USA b Department of Endocrinology, Washington Hospital Center, 110 Irving Street NW, Room 2A-72, Washington DC 20010-2975, USA c Departmentof Medicine, Georgetown University, 110 Irving Street NW, Room 2A-72, Washington DC 20010, USA
In the spectrum of endocrine emergencies, thyroid storm ranks as one of the most critical illnesses. Recognition and appropriate management of life-threatening thyrotoxicosis is vital to prevent the high morbidity and mortality that may accompany this disorder. The incidence of thyroid storm hasbeen noted to be less than 10% of patients hospitalized for thyrotoxicosis; however, the mortality rate due to thyroid storm ranges from 20 to 30% [1,2]. In common parlance, whereas hyperthyroidism refers to disorders that result from overproduction of hormone from the thyroid gland, thyrotoxicosis refers to any cause of excessive thyroid hormone concentration. Thyroid storm represents the extrememanifestation of thyrotoxicosis . The point at which thyrotoxicosis transforms to thyroid storm is controversial, and is, to some degree, subjective. In an eﬀort to standardize and objectify thyroid storm somewhat, as compared with severe thyrotoxicosis, Burch and Wartofsky  have delineated a point system assessing degrees of dysfunction in various systems (thermoregulatory, centralnervous, gastrointestinal, and cardiovascular), as shown in Table 1. However, clinically, it is prudent to assume that someone with severe thyrotoxicosis has impending thyroid storm, and to treat them aggressively, rather than focus on speciﬁc deﬁnitions. Etiology The most common underlying cause of thyrotoxicosis in cases of thyroid storm is Graves’ disease. Graves’ disease is mediated by thethyrotropin
* Corresponding author. Department of Endocrinology, Washington Hospital Center, 110 Irving Street NW, Room 2A-72, Washington DC 20010-2975. E-mail address: Kenneth.firstname.lastname@example.org (K. Burman). 0889-8529/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ecl.2006.09.008 endo.theclinics.com
664 Table 1 Diagnostic criteria for thyroid storm Diagnosticparameters Thermoregulatory dysfunction Temperature 99–99.9 100–100.9 101–101.9 102–102.9 103–103.9 R104.0
NAYAK & BURMAN
5 10 15 20 25 30 0 10 20 30 0 10 20
Central nervous system eﬀects Absent Mild (agitation) Moderate (delirium, psychosis, extreme lethargy Severe (seizures, coma) Gastrointestinal-hepatic dysfunction Absent Moderate (diarrhea, nausea/vomiting, abdominalpain) Severe (unexplained jaundice) Cardiovascular dysfunction Tachycardia (beats/minute) 90–109 110–119 120–129 R140 Congestive heart failure Absent Mild (pedal edema) Moderate (bibasilar rales) Severe (pulmonary edema) Atrial ﬁbrillation Absent Present Precipitating event Absent Present
5 10 15 25 0 5 10 15 0 10 0 10
Scoring system: A score of 45 or greater is highly suggestive of thyroidstorm; a score of 25– 44 is suggestive of impending storm, and a score below 25 is unlikely to represent thyroid storm. Adapted from Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22(2):263–77.
receptor antibodies that stimulate excess and uncontrolled thyroidal synthesis and secretion of thyroid hormones (thyroxine [T4] ortriiodothyronine [T3]). It occurs most frequently in young women, but can occur in either sex and any age group. However, thyroid storm can also occur with a solitary toxic adenoma or toxic multinodular goiter. Rare causes of thyrotoxicosis leading to thyroid storm would include hypersecretory thyroid
THYROTOXICOSIS AND THYROID STORM
carcinoma, thyrotropin-secreting pituitary adenoma, struma...