eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Thyroid Storm: Differential Diagnoses & Workup

Author: Madhusmita Misra, MD, Assistant in Pediatrics, Mass General Hospital for Children, Harvard Medical School; Assistant Professor of Pediatrics, Fellowship Program Director, Department of Pediatric Endocrinology, Massachusetts General Hospital
Coauthor(s): Abhay Singhal, MD, Assistant Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Indiana University School of Medicine; Deborah E Campbell, MD, Professor of Clinical Pediatrics, Albert Einstein College of Medicine; Director, Department of Pediatrics, Division of Neonatology, Weiler Hospital Division of Montefiore Medical Center
Contributor Information and Disclosures

Updated: Jun 4, 2009

Differential Diagnoses

Anxiety Disorder: Panic Disorder
Heart Failure, Congestive
Hypertension
Hyperthyroidism
Pheochromocytoma
Supraventricular Tachycardia, Atrial Ectopic Tachycardia

Other Problems to Be Considered

Anticholinergic or adrenergic drug intoxication
CNS infections
Hypertensive encephalopathy
Malignant hyperthermia
Septic shock

Workup

Laboratory Studies

Thyroid storm diagnosis is based on clinical features, not on laboratory test findings. If the patient's clinical picture is consistent with thyroid storm, do not delay treatment pending laboratory confirmation of thyrotoxicosis.

  • Thyroid studies
    • Results of thyroid studies are usually consistent with hyperthyroidism and are useful only if the patient has not been previously diagnosed.
    • Test results may not come back quickly and are usually unhelpful for immediate management.
    • Usual findings include elevated triiodothyronine (T3), thyroxine (T4) and free T4 levels; increased T3 resin uptake; suppressed thyroid-stimulating hormone (TSH) levels; and an elevated 24-hour iodine uptake. TSH levels are not suppressed in the rare instances of excess TSH secretion.
  • CBC count: CBC count reveals mild leukocytosis, with a shift to the left.
  • Liver function tests (LFTs): LFTs commonly reveal nonspecific abnormalities such as elevated levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatinine kinase, alkaline phosphatase, and serum bilirubin.
  • ABG and urinalysis: Measurement of blood gas and electrolyte levels and urinalysis testing may be performed to assess and monitor short-term management.

Imaging Studies

  • Chest radiography
    • Chest radiography may reveal cardiac enlargement due to congestive heart failure.
    • Radiography may also reveal pulmonary edema caused by heart failure and/or evidence of pulmonary infection.
  • CT scanning: Head CT scanning may be necessary to exclude other neurologic conditions if diagnosis is uncertain after the initial stabilization of a patient who presents with altered mental status.

Other Tests

  • ECG is useful in monitoring for cardiac arrhythmias. Atrial fibrillation is the most common cardiac arrhythmia associated with thyroid storm. Other arrhythmias such as atrial flutter and, less commonly, ventricular tachycardia may also occur.

More on Thyroid Storm

Overview: Thyroid Storm
Differential Diagnoses & Workup: Thyroid Storm
Treatment & Medication: Thyroid Storm
Follow-up: Thyroid Storm
References
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References

  1. Aiello DP, DuPlessis AJ, Pattishall EG 3d, Kulin HE. Thyroid storm. Presenting with coma and seizures. In a 3-year-old girl. Clin Pediatr (Phila). - DuPlessis AJ;28(12):571-4. [Medline].

  2. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. Jun 1993;22(2):263-77. [Medline].

  3. Hasan MK, Tierney WM, Baker MZ. Severe cholestatic jaundice in hyperthyroidism after treatment with 131-iodine. Am J Med Sci. Dec 2004;328(6):348-50. [Medline].

  4. Hirvonen EA, Niskanen LK, Niskanen MM. Thyroid storm prior to induction of anaesthesia. Anaesthesia. Oct 2004;59(10):1020-2. [Medline].

  5. Kadmon PM, Noto RB, Boney CM, et al. Thyroid storm in a child following radioactive iodine (RAI) therapy: a consequence of RAI versus withdrawal of antithyroid medication. J Clin Endocrinol Metab. May 2001;86(5):1865-7. [Medline]. [Full Text].

  6. Al-Anazi KA, Inam S, Jeha MT, Judzewitch R. Thyrotoxic crisis induced by cytotoxic chemotherapy. Support Care Cancer. Mar 2005;13(3):196-8. [Medline].

  7. Lawless ST, Reeves G, Bowen JR. The development of thyroid storm in a child with McCune-Albright syndrome after orthopedic surgery. Am J Dis Child. Sep 1992;146(9):1099-102. [Medline].

  8. FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). US Food and Drug Administration. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm164162.htm. Accessed June 3, 2009.

  9. Petry J, Van Schil PE, Abrams P, Jorens PG. Plasmapheresis as effective treatment for thyrotoxic storm after sleeve pneumonectomy. Ann Thorac Surg. May 2004;77(5):1839-41. [Medline].

  10. Knighton JD, Crosse MM. Anesthetic management of childhood thyrotoxicosis and the use of esmolol. Anaesthesia. 1997;52(1):67-70. [Medline].

  11. Misra M, Levitsky LL, Lee MM. Transient hyperthyroidism in an adolescent with hydatidiform mole. J Pediatr. Mar 2002;140(3):362-6. [Medline].

  12. Morrison MP, Schroeder A. Intraoperative identification and management of thyroid storm in children. Otolaryngol Head Neck Surg. Jan 2007;136(1):132-3. [Medline].

  13. Ngo AS, Jung Tan DC. Thyrotoxic heart disease. Resuscitation. Jun 26 2006;[Medline].

  14. Rogers MC, Nichols DG. Thyroid storm. In: Textbook of Pediatric Intensive Care. 3rd ed. Baltimore, MD: Williams & Williams; 1996:1291-95.

  15. Sebe A, Satar S, Sari A. Thyroid storm induced by aspirin intoxication and the effect of hemodialysis: a case report. Adv Ther. May-Jun 2004;21(3):173-7. [Medline].

  16. Tietgens ST, Leinung MC. Thyroid Storm. Medical Clinics of North America. 1995;79(1):169-84. [Medline].

  17. Ureta-Raroque SS, Abramo TJ. Adolescent female patient with shock unresponsive to usual resuscitative therapy. Pediatr Emerg Care. Aug 1997;13(4):274-6. [Medline].

  18. Wartofsky L. Thyroid storm. In: Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text. 6th ed. 1991:871-79.

  19. Wilson BE, Hobbs WN. Case report: pseudoephedrine-associated thyroid storm: thyroid hormone- catecholamine interactions. Am J Med Sci. Nov 1993;306(5):317-9. [Medline].

  20. Yoon SJ, Kim DM, Kim JU, et al. A case of thyroid storm due to thyrotoxicosis factitia. Yonsei Med J. Apr 30 2003;44(2):351-4. [Medline].

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Further Reading

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Keywords

thyroid storm, thyrotoxic crisis, thyrotoxicosis, thyroid hormones, TH, hypertension, congestive heart failure, hypotension, shock, heat intolerance, tachycardia, delirium, seizures, diarrhea, jaundice, vomiting, abdominal pain, Graves disease, respiratory distress, fatigue, atrial flutter, atrial fibrillation, goiter, McCune-Albright syndrome, juvenile rheumatoid arthritis, Addison disease, type I diabetes, myasthenia gravis, chronic lymphocytic thyroiditis, Hashimoto thyroiditis, systemic lupus erythematosus, chronic active hepatitis, nephrotic syndrome

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Contributor Information and Disclosures

Author

Madhusmita Misra, MD, Assistant in Pediatrics, Mass General Hospital for Children, Harvard Medical School; Assistant Professor of Pediatrics, Fellowship Program Director, Department of Pediatric Endocrinology, Massachusetts General Hospital
Madhusmita Misra, MD is a member of the following medical societies: Endocrine Society and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Tercica Grant/research funds Principal investigator; Ipsen Consulting fee Review panel membership

Coauthor(s)

Abhay Singhal, MD, Assistant Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Indiana University School of Medicine
Abhay Singhal, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Deborah E Campbell, MD, Professor of Clinical Pediatrics, Albert Einstein College of Medicine; Director, Department of Pediatrics, Division of Neonatology, Weiler Hospital Division of Montefiore Medical Center
Deborah E Campbell, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Medical Association, National Perinatal Association, New York Academy of Medicine, and New York Academy of Sciences
Disclosure: Nothing to disclose.

Medical Editor

Phyllis W Speiser, MD, Chief of Pediatric Endocrinology, Schneider Children's Hospital; Professor of Pediatrics, New York University School of Medicine
Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Lynne Lipton Levitsky, MD, Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor, Department of Pediatrics, Harvard University Medical School
Lynne Lipton Levitsky, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Diabetes Association, American Pediatric Society, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Pfizer Grant/research funds P.I.; Tercica Grant/research funds PI, also occasional consultant

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD, Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and Arkansas Children's Hospital
Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Genentech, Inc. Honoraria Speaking and teaching; Pfizer, Inc. Honoraria Consulting

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