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thyroid storm

Extreme manifestation of thyrotoxicosis. Life-threatening complication of hyperthyroidism. Etiology: 1) precipitating factors* a) infection (most common) b) surgical stress or anesthesia c) sudden withdrawal of thionamide (PTU, methimazole) d) large doses of I-131 given to severely thyrotoxic patient with large goiter - generally occurs within 7-10 days post therapy e) myocardial infarction f) iodine contained in contrast agents for radiographic studies (angiography) in patients with Graves disease [2] g) parturition, labor & delivery 2) untreated Graves disease* * most commonly Graves disease in combination with preciptating factor(s) Epidemiology: - rare Pathology: 1) acute release of preformed hormone 2) no correlation between level of circulating level of T4 & severity of symptoms Clinical manifestations: 1) acutely ill patient with exacerbated symptoms of thyrotoxicosis, hyperthyroidism 2) fever > 100 degrees F 3) tachycardia > 120/min, atrial fibrillation, heart failure 4) hypotension, shock 5) abdominal pain, nausea, vomiting, diarrhea 6) jaundice 7) lid lag &/or signs/symptoms of Graves ophthalmopathy 8) delirium, psychosis 9) seizures, apathy, stupor & coma as condition worsens 10) elderly patients may lack hyperkinetic features & present with lethargy & cardiac manifestations only 11) patients on beta blockers may have blunted manifestations Laboratory: 1) see hyperthyroidism 2) increased free T4, free T3 3) abnormal liver function tests * clinical diagnosis; no level of thyroxine is diagnostic [2] Complications: - mortality 15-20% with treatment [2] - mortality may be as high as 30% [2] Management: 1) decrease conversion of T4 -> T3 a) use IV propranolol in ICU b) propylthiouracil (methimazole does not do this) c) dexamethasone (4-8 mg/day) 2) decrease release of thyroid hormone a) saturated solution of KI (SSKI): 5-10 drops in water b) Lugol's solution: 5-10 drops c) 1 g NaI IV over 8-10 hours 3) treat associated adrenal dysfunction - hydrocortisone 4) treat associated thermoregulatory dysfunction a) cooling blanklets b) acetamionphen 5) treat precipitating factors 6) reverse systemic decompensation 7) lithium carbonate is rarely used [2] 8) poor outcome is associated with: a) circulatory collapse b) obtundation c) jaundice (in absence of CHF) 9) plasmapheresis - evidence supporting use of plasmapheresis is from case reports [2] - generally reserved for patients in whom standard therapy has failed

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hyperthyroidism

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thyrotoxicosis

References

  1. Contributions from Paulette Ginier Dept of Endocrinology, UCSF Fresno
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015. 2018 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86 PMID: 17127140
  4. Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am. 2012 Mar;96(2):385-403 PMID: 22443982
  5. Hampton J. Thyroid gland disorder emergencies: thyroid storm and myxedema coma. AACN Adv Crit Care. 2013 Jul-Sep;24(3):325-32. Review. PMID: 23880755
  6. Sharp CS, Wilson MP, Nordstrom K. Psychiatric Emergencies for Clinicians: The Emergency Department Management of Thyroid Storm. J Emerg Med. 2016 May 30. pii: S0736-4679(16)00044-5. PMID: 27256626
  7. Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am. 2012 Mar;96(2):385-403. Review. PMID: 22443982
  8. Feldt-Rasmussen U, Emerson CH, Ross DS, et al. Thoughts on the Japanese and American perspectives on thyroid storm [Editorial]. Thyroid. 2019;29:1033-1035. PMID: 31140377