Hyperthyroidism, Thyroid Storm, and Graves Disease in Emergency Medicine Clinical Presentation

  • Author: Erik D Schraga, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 29, 2012
 

History

The clinical presentation of hyperthyroidism ranges from an array of nonspecific historical features to an acute life-threatening event. Historical features common to hyperthyroidism and thyroid storm are numerous and represent a hypermetabolic state with increased beta-adrenergic activity.

  • Weight loss
    • Patients typically report an average loss of approximately 15% of their prior weight.
    • Basal metabolic rate is increased with a stimulation of lipolysis and lipogenesis.
  • Palpitations
  • Chest pain - Often occurs in the absence of cardiovascular disease
  • Psychosis
  • Menstrual irregularity
  • Disorientation
  • Tremor
  • Nervousness, anxiety, or emotional lability
  • Heat intolerance
  • Increased perspiration
  • Fatigue
  • Weakness - Typically affects proximal muscle groups
  • Edema
  • Dyspnea
  • Frequent bowel movements
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Physical

  • Fever
  • Tachycardia (often out of proportion to the fever)
  • Diaphoresis (often profuse)
  • Dehydration secondary to GI losses and diaphoresis
  • Warm, moist skin
  • Widened pulse pressure
  • Congestive heart failure (may be a high output failure)
  • Thyromegaly
    • Nontender, diffuse enlargement in Graves disease
    • Tender, diffusely enlarged gland in thyroiditis
    • Thyroid nodules, either single or multinodular goiter
  • Exophthalmos
  • Shock
  • Atrial fibrillation
    • Typically in elderly patients
    • May be refractory to attempted rate control with digitalis
    • Converts after antithyroid therapy in 20-50% of patients
  • Myopathy
  • Thyroid bruit - Relatively specific for thyrotoxicosis
  • Fine, resting tremor
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Causes

Hyperthyroidism results from numerous etiologies, including autoimmune, drug-induced, infectious, idiopathic, iatrogenic, and malignancy.

  • Autoimmune
    • Graves disease
    • Chronic thyroiditis (Hashimoto thyroiditis) - Although the primary cause of hypothyroidism, the disease process occasionally presents initially with thyrotoxicosis
    • Subacute thyroiditis (de Quervain thyroiditis) - Diffuse, painful inflammation of the thyroid producing a transient state leakage of stored hormone
    • Postpartum thyroiditis - Presents similarly to subacute thyroiditis 2-6 months postpartum but typically painless with mild symptoms
  • Drug-induced
    • Iodine-induced - Occurs after administration of either supplemental iodine to those with prior iodine deficiency or pharmacologic doses of iodine (contrast media, medications) in those with underlying nodular goiter
    • Amiodarone - Its high iodine content is primarily responsible for producing a hyperthyroid state, though the medication may itself induce autoimmune thyroid disease.
    • Antineoplastic agents - Agents may cause thyroid dysfunction in 20-50% of patients. Symptoms of thyrotoxicosis may be mistaken for sepsis or an adverse drug effect, so monitoring of thyroid function must be considered.[2]
  • Infectious
    • Suppurative thyroiditis - Often bacterial, results in a painful gland commonly in those with underlying thyroid disease or in immunocompromised individuals
    • Postviral thyroiditis
  • Idiopathic
    • Toxic multinodular goiter - The second most common cause of hyperthyroidism, characterized by functionally autonomous nodules, typically after age 50 years
  • Iatrogenic
    • Thyrotoxicosis factitia - A psychiatric condition in which high quantities of exogenous thyroid hormone are consumed
    • Surgery - Now uncommon secondary to preventative measures, manipulation of the thyroid gland during thyroidectomy historically caused a flood of hormone release, often resulting in highly toxic blood levels
  • Malignancy
    • Toxic adenoma - A single, hyperfunctioning nodule within a normally functioning thyroid gland commonly among patients in their 30s and 40s
    • Thyrotropin-producing pituitary tumors
    • Struma ovarii - Ovarian teratoma with ectopic thyroid tissue
  • Thyroid storm can be triggered by many different events, classically in patients with underlying Graves disease or toxic multinodular goiter.
    • Infection
    • Surgery
    • Cardiovascular events
    • Toxemia of pregnancy
    • Diabetic ketoacidosis, hyperosmolar coma, and insulin-induced hypoglycemia
    • Thyroidectomy
    • Discontinuation of antithyroid medication
    • Radioactive iodine
    • Vigorous palpation of the thyroid gland in hyperthyroid patients
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Contributor Information and Disclosures
Author

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

Robin R Hemphill, MD, MPH  Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Howard A Bessen, MD  Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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