Hyperthyroidism, Thyroid Storm, and Graves Disease Clinical Presentation

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

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

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. ^[13]

• 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