Hyperthyroidism, Thyroid Storm, and Graves Disease Clinical Presentation

Updated: Apr 10, 2017
  • Author: Erik D Schraga, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Presentation

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

See the list below:

  • 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
    • 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. [4]
  • 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
  • Miscellaneous
    • 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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