- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis . In a national survey from Japan, the incidence of thyroid storm in hospitalized patients was 0.20 per 100,000 per year . It may be precipitated by an acute event such as thyroid or nonthyroidal surgery, trauma, infection, an acute iodine load, or parturition. In addition to specific therapy directed against the thyroid, supportive therapy in an intensive care unit (ICU) and recognition and treatment of any precipitating factors is essential, since the mortality rate of thyroid storm is substantial (10 to 30 percent) [2-4].
The clinical manifestations, diagnosis, and management of thyroid storm will be reviewed here. The general topic of hyperthyroidism (without thyroid storm), including diagnosis, causes, and treatment, is reviewed separately. (See "Overview of the clinical manifestations of hyperthyroidism in adults" and "Diagnosis of hyperthyroidism" and "Disorders that cause hyperthyroidism" and "Graves' hyperthyroidism in nonpregnant adults: Overview of treatment" and "Hyperthyroidism during pregnancy: Treatment" and "Treatment of toxic adenoma and toxic multinodular goiter".)
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 or nonthyroidal surgery, trauma, infection, an acute iodine load, or parturition. In addition, irregular use or discontinuation of antithyroid drugs is a commonly reported precipitant of thyroid storm [2,3]. The advent of appropriate preoperative preparation of hyperthyroid patients undergoing nonthyroidal surgery or thyroidectomy for hyperthyroidism has led to a dramatic reduction in the prevalence of surgically-induced thyroid storm.
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 . The degree of thyroid hormone excess (elevation of thyroxine [T4] and triiodothyronine [T3], suppression of thyroid-stimulating hormone [TSH]) 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 .
Patients with severe and life-threatening thyrotoxicosis typically have an exaggeration of the usual symptoms of hyperthyroidism. (See "Overview of the clinical manifestations of hyperthyroidism in adults".)
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- RISK FACTORS
- CLINICAL FEATURES
- Symptoms and signs
- Laboratory findings
- Our initial approach
- - Beta blockers
- - Thionamides
- Patients unable to take a thionamide
- - Iodine
- - Iodinated radiocontrast agents
- - Glucocorticoids
- - Bile acid sequestrants
- Other therapies
- Long-term management
- SUMMARY AND RECOMMENDATIONS