Thyroid Storm Workup
- Author: Madhusmita Misra, MD, MPH; Chief Editor: Stephen Kemp, MD, PhD more...
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.
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.
- Hypercalcemia may occur from thyrotoxicosis.
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.
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.
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.
Aiello DP, DuPlessis AJ, Pattishall EG 3rd, Kulin HE. Thyroid storm. Presenting with coma and seizures. In a 3-year-old girl. Clin Pediatr (Phila). 1989 Dec. 28 (12):571-4. [Medline].
Hirvonen EA, Niskanen LK, Niskanen MM. Thyroid storm prior to induction of anaesthesia. Anaesthesia. 2004 Oct. 59(10):1020-2. [Medline].
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. 2001 May. 86(5):1865-7. [Medline]. [Full Text].
Alkhuja S, Pyram R, Odeyemi O. In the eye of the storm: iodinated contrast medium induced thyroid storm presenting as cardiopulmonary arrest. Heart Lung. 2013 Jul-Aug. 42(4):267-9. [Medline].
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. 1992 Sep. 146(9):1099-102. [Medline].
Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan. Medicine (Baltimore). 2016 Feb. 95 (7):e2848. [Medline].
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 Feb 1. 21 (2):182-9. [Medline].
Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993 Jun. 22(2):263-77. [Medline].
Hasan MK, Tierney WM, Baker MZ. Severe cholestatic jaundice in hyperthyroidism after treatment with 131-iodine. Am J Med Sci. 2004 Dec. 328(6):348-50. [Medline].
Umezu T, Ashitani K, Toda T, Yanagawa T. A patient who experienced thyroid storm complicated by rhabdomyolysis, deep vein thrombosis, and a silent pulmonary embolism: a case report. BMC Res Notes. 2013 May 20. 6(1):198. [Medline]. [Full Text].
US Food and Drug Administration. FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). Available at http://bit.ly/s0sNi. Accessed: June 3, 2009.
Petry J, Van Schil PE, Abrams P, Jorens PG. Plasmapheresis as effective treatment for thyrotoxic storm after sleeve pneumonectomy. Ann Thorac Surg. 2004 May. 77(5):1839-41. [Medline].
Al-Anazi KA, Inam S, Jeha MT, Judzewitch R. Thyrotoxic crisis induced by cytotoxic chemotherapy. Support Care Cancer. 2005 Mar. 13(3):196-8. [Medline].
Knighton JD, Crosse MM. Anesthetic management of childhood thyrotoxicosis and the use of esmolol. Anaesthesia. 1997. 52(1):67-70. [Medline].
Misra M, Levitsky LL, Lee MM. Transient hyperthyroidism in an adolescent with hydatidiform mole. J Pediatr. 2002 Mar. 140(3):362-6. [Medline].
Morrison MP, Schroeder A. Intraoperative identification and management of thyroid storm in children. Otolaryngol Head Neck Surg. 2007 Jan. 136(1):132-3. [Medline].
Ngo AS, Jung Tan DC. Thyrotoxic heart disease. Resuscitation. 2006 Jun 26. [Medline].
Rogers MC, Nichols DG. Thyroid storm. Textbook of Pediatric Intensive Care. Baltimore, MD: Williams & Williams; 1996. 3rd ed: 1291-95.
Sebe A, Satar S, Sari A. Thyroid storm induced by aspirin intoxication and the effect of hemodialysis: a case report. Adv Ther. 2004 May-Jun. 21(3):173-7. [Medline].
Tietgens ST, Leinung MC. Thyroid Storm. Medical Clinics of North America. 1995. 79(1):169-84. [Medline].
Ureta-Raroque SS, Abramo TJ. Adolescent female patient with shock unresponsive to usual resuscitative therapy. Pediatr Emerg Care. 1997 Aug. 13(4):274-6. [Medline].
Wartofsky L. Thyroid storm. Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text. 6th ed. 1991. 871-79.
Wilson BE, Hobbs WN. Case report: pseudoephedrine-associated thyroid storm: thyroid hormone- catecholamine interactions. Am J Med Sci. 1993 Nov. 306(5):317-9. [Medline].
Yoon SJ, Kim DM, Kim JU, et al. A case of thyroid storm due to thyrotoxicosis factitia. Yonsei Med J. 2003 Apr 30. 44(2):351-4. [Medline].