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Thyrotoxic Storm Following Thyroidectomy Clinical Presentation

  • Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jan 21, 2015
 

History

Clinical features form the hallmark in diagnosing thyroid storm. Most patients have goiter, and many of those with Graves disease have concurrent ophthalmopathy. Frequently, a past history of thyroid disease that has been partially treated exists.

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Physical

An accentuation of signs and symptoms is seen in uncomplicated thyrotoxicosis. The point of transition from uncomplicated thyrotoxicosis to thyroid storm is difficult to ascertain. Very few criteria define the change. However, certain clinical features (eg, high-grade fever, mental obtundation, decompensation of one or more organ systems secondary to the severe state of hypermetabolism) herald its onset.

The table below presents some changes in the symptoms and signs of thyroid storm when compared with uncomplicated thyrotoxicosis. Importantly, some findings of thyroid storm (eg, atrial dysrhythmia) may also prevail in uncomplicated thyrotoxicosis. Therefore, the table represents only guidelines, not specific criteria to define thyroid storm.

Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis (Open Table in a new window)

Uncomplicated Thyrotoxicosis Thyroid Storm
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure
3. Diarrhea, increased appetite with loss of weight 3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice
4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma

Certain unusual presentations include chest pain, acute abdomen, status epilepticus, stroke, acute renal failure due to rhabdomyolysis, and apathetic thyroidism. Lahey first described apathetic thyroidism (ie, masked hyperthyroidism) 60 years ago.[1] Apathetic thyroidism more frequently was seen in elderly patients but since has been described in all ages. Patients in this variant group present without goiter, ophthalmopathy, or prominent symptoms of hyperthyroidism. These patients have a low pulse rate and a propensity to develop thyroid storm due to delay in diagnosis.

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Causes

A precipitating factor usually is found with thyroid storm. Presently, the most common cause of thyroid storm is intercurrent illness or infection (ie, medical storm).[2, 3]

Some causes that rapidly increase the thyroid hormone levels include the following:

  • Surgery, thyroidal or nonthyroidal
  • Radioiodine therapy
  • Withdrawal of antithyroid drug therapy
  • Vigorous thyroid palpation
  • Iodinated contrast dye
  • Thyroid hormone ingestion

Other common precipitants include the following:

  • Infection
  • Emotional stress
  • Tooth extraction
  • Diabetic ketoacidosis
  • Hypoglycemia
  • Trauma
  • Bowel infarction
  • Parturition
  • Toxemia of pregnancy
  • Pulmonary embolism
  • Cerebrovascular accident
  • Gestational trophoblastic disease
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Contributor Information and Disclosures
Author

Peter F Czako, MD, FACS Chief, Division of Endocrine Surgery, Medical Director, North Tower Operating Rooms, Surgical Administration, William Beaumont Hospital; Associate Professor, Department of Surgery, Oakland University William Beaumont School of Medicine; Royal Oak Surgical Associates, PC

Peter F Czako, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Michigan State Medical Society, American Association of Endocrine Surgeons, Detroit Surgical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nafisa K Kuwajerwala, MD Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast Disease

Disclosure: Nothing to disclose.

Gunateet Goswami, MD Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital

Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, Michigan State Medical Society

Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers

Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India

Pankaj Chaturvedi, MBBS, MS, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India

Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD Fellow in Bariatric/Advanced Laparoscopic Surgery, University of Missouri Healthcare

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dean Toriumi, MD Associate Professor, Department of Otolaryngology, University of Illinois Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Mimi S Kokoska, MD Physician, Department of Otolaryngology-Head and Neck Surgery, Aurora Health Care

Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American College of Surgeons, American Head and Neck Society

Disclosure: Nothing to disclose.

References
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Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis
Uncomplicated Thyrotoxicosis Thyroid Storm
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure
3. Diarrhea, increased appetite with loss of weight 3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice
4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma
Previous
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