- 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) [2-5].
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 longstanding 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".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord 2003; 4:129.
- Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012; 22:661.
- Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract 2015; 21:182.
- Angell TE, Lechner MG, Nguyen CT, et al. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. J Clin Endocrinol Metab 2015; 100:451.
- Ono Y, Ono S, Yasunaga H, et al. Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan. Medicine (Baltimore) 2016; 95:e2848.
- Brooks MH, Waldstein SS. Free thyroxine concentrations in thyroid storm. Ann Intern Med 1980; 93:694.
- Ngo SY, Chew HC. When the storm passes unnoticed--a case series of thyroid storm. Resuscitation 2007; 73:485.
- Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006; 35:663.
- Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993; 22:263.
- Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. J Intensive Care Med 2015; 30:131.
- Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343.
- Cooper DS, Daniels GH, Ladenson PW, Ridgway EC. Hyperthyroxinemia in patients treated with high-dose propranolol. Am J Med 1982; 73:867.
- Das G, Krieger M. Treatment of thyrotoxic storm with intravenous administration of propranolol. Ann Intern Med 1969; 70:985.
- Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med 1991; 9:232.
- Milner MR, Gelman KM, Phillips RA, et al. Double-blind crossover trial of diltiazem versus propranolol in the management of thyrotoxic symptoms. Pharmacotherapy 1990; 10:100.
- Cooper DS, Saxe VC, Meskell M, et al. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab 1982; 54:101.
- Abuid J, Larsen PR. Triiodothyronine and thyroxine in hyperthyroidism. Comparison of the acute changes during therapy with antithyroid agents. J Clin Invest 1974; 54:201.
- Isozaki O, Satoh T, Wakino S, et al. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol (Oxf) 2016; 84:912.
- Satoh T, Isozaki O, Suzuki A, et al. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J 2016; 63:1025.
- Nabil N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab 1982; 54:180.
- Walter RM Jr, Bartle WR. Rectal administration of propylthiouracil in the treatment of Graves' disease. Am J Med 1990; 88:69.
- Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid 1995; 5:403.
- Jongjaroenprasert W, Akarawut W, Chantasart D, et al. Rectal administration of propylthiouracil in hyperthyroid patients: comparison of suspension enema and suppository form. Thyroid 2002; 12:627.
- Hodak SP, Huang C, Clarke D, et al. Intravenous methimazole in the treatment of refractory hyperthyroidism. Thyroid 2006; 16:691.
- Giles HG, Roberts EA, Orrego H, Sellers EM. Disposition of intravenous propylthiouracil. J Clin Pharmacol 1981; 21:466.
- Gregoire G, Aris-Jilwan N, Ninet B, et al. Intravenous administration of propylthiouracil in treatment of a patient with Graves' disease (abstract). 77th Annual Meeting, The Endocrine Society, 1995, Abstract P3-464.
- Kandil E, Khalek MA, Thethi T, et al. Thyroid storm in a patient with fulminant hepatic failure. Laryngoscope 2011; 121:164.
- Vyas AA, Vyas P, Fillipon NL, et al. Successful treatment of thyroid storm with plasmapheresis in a patient with methimazole-induced agranulocytosis. Endocr Pract 2010; 16:673.
- Panzer C, Beazley R, Braverman L. Rapid preoperative preparation for severe hyperthyroid Graves' disease. J Clin Endocrinol Metab 2004; 89:2142.
- Langley RW, Burch HB. Perioperative management of the thyrotoxic patient. Endocrinol Metab Clin North Am 2003; 32:519.
- Benua RS, Becker DV, Hurley JR. Thyroid storm. In: Current Therapy in Endocrinology and Metabolism, Bardin CW (Ed), Mosby, St. Louis 1994. p.75.
- Kinoshita H, Yasuda M, Furumoto Y, et al. Severe duodenal hemorrhage induced by Lugol's solution administered for thyroid crisis treatment. Intern Med 2010; 49:759.
- Park JM, Seok Lee I, Young Kang J, et al. Acute esophageal and gastric injury: complication of Lugol's solution. Scand J Gastroenterol 2007; 42:135.
- Roti E, Robuschi G, Gardini E, et al. Comparison of methimazole, methimazole and sodium ipodate, and methimazole and saturated solution of potassium iodide in the early treatment of hyperthyroid Graves' disease. Clin Endocrinol (Oxf) 1988; 28:305.
- Baeza A, Aguayo J, Barria M, Pineda G. Rapid preoperative preparation in hyperthyroidism. Clin Endocrinol (Oxf) 1991; 35:439.
- Tsatsoulis A, Johnson EO, Kalogera CH, et al. The effect of thyrotoxicosis on adrenocortical reserve. Eur J Endocrinol 2000; 142:231.
- Mazzaferri EL, Skillman TG. Thyroid storm. A review of 22 episodes with special emphasis on the use of guanethidine. Arch Intern Med 1969; 124:684.
- Solomon BL, Wartofsky L, Burman KD. Adjunctive cholestyramine therapy for thyrotoxicosis. Clin Endocrinol (Oxf) 1993; 38:39.
- Kaykhaei MA, Shams M, Sadegholvad A, et al. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine 2008; 34:52.
- Tsai WC, Pei D, Wang TF, et al. The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves' hyperthyroidism. Clin Endocrinol (Oxf) 2005; 62:521.
- Petry J, Van Schil PE, Abrams P, Jorens PG. Plasmapheresis as effective treatment for thyrotoxic storm after sleeve pneumonectomy. Ann Thorac Surg 2004; 77:1839.
- Koball S, Hickstein H, Gloger M, et al. Treatment of thyrotoxic crisis with plasmapheresis and single pass albumin dialysis: a case report. Artif Organs 2010; 34:E55.
- Muller C, Perrin P, Faller B, et al. Role of plasma exchange in the thyroid storm. Ther Apher Dial 2011; 15:522.
- Carhill A, Gutierrez A, Lakhia R, Nalini R. Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis. BMJ Case Rep 2012; 2012.
- 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