Hyperthyroidism, Thyroid Storm, and Graves Disease Clinical Presentation

Updated: Apr 03, 2018
  • 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. [7]

  • 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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