History and Physical Examination

History

Access to thyroid hormone or other pharmaceuticals, especially in pediatric or unknown ingestions, is important to diagnosis and management. Reported symptoms may include:

Abdominal pain
Nausea or vomiting
Diarrhea
Increased appetite
Insomnia
Anxiousness
Agitation
Tremor
Weakness

Physical examination

Focus the physical examination on findings consistent with symptoms of increased adrenergic activity as below.

Acute signs include:

Tachycardia
Palpitations or Arrhythmia
Hypertension or hypotension
Hyperpyrexia/heat intolerance
Tremor
Seizures
Weakness
Diaphoresis
Confusion
Psychosis
Hypoglycemia
Skin flushing
Transient systolic ejection murmurs
Pulmonary edema
Adrenal insufficiency

Chronic signs are as follows:

Weight loss
Menstrual irregularities
Supraventricular tachycardia (SVT)
High-output left ventricular failure
Hypotension
Hemiparesis
Delirium
Coma
Pneumonia
Sepsis
Hyperthermia
Acute renal failure
Myopathy
Palmar and plantar desquamation
Premature epiphyseal closure in children
Craniosynostosis (infants)

Differential Diagnoses

Yamada M, Mori M. Mechanisms related to the pathophysiology and management of central hypothyroidism. Nat Clin Pract Endocrinol Metab. 2008 Dec. 4(12):683-94. [QxMD MEDLINE Link]. [Full Text].
Kang GY, Parks JR, Fileta B, Chang A, Abdel-Rahim MM, Burch HB, et al. Thyroxine and triiodothyronine content in commercially available thyroid health supplements. Thyroid. 2013 October. 23(10):1233-7. [QxMD MEDLINE Link].
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, et al. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021 Dec. 59 (12):1282-1501. [QxMD MEDLINE Link].
Ergul AB, Altuner Torun Y, Serbetci MC, Ozcan A, Bas VN. Clinical toxicity of acute overdoses with L-thyroxin in children. Pediatr Emerg Care. 2019 Nov. 35 (11):787-90. [QxMD MEDLINE Link].
Litovitz TL, White JD. Levothyroxine ingestions in children: an analysis of 78 cases. Am J Emerg Med. 1985 Jul. 3(4):297-300. [QxMD MEDLINE Link].
Golightly LK, Smolinske SC, Kulig KW, Wruk KM, Gelman CJ, Rumack BH. Clinical effects of accidental levothyroxine ingestion in children. Am J Dis Child. 1987 Sep. 141(9):1025-7. [QxMD MEDLINE Link].
FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). US Food and Drug Administration. Accessed: 2016-02-12.
Bauer LA. Simulations of Levothyroxine Bioavailability Using a Single-Dose Study Protocol. Am J Ther. 1995 Jun. 2(6):414-416. [QxMD MEDLINE Link].
Berkner PD, Starkman H, Person N. Acute L-thyroxine overdose; therapy with sodium ipodate: evaluation of clinical and physiologic parameters. J Emerg Med. 1991 May-Jun. 9(3):129-31. [QxMD MEDLINE Link].
Bosse GM, Matyunas NJ. Delayed toxidromes. J Emerg Med. 1999 Jul-Aug. 17(4):679-90. [QxMD MEDLINE Link].
Lehrner LM, Weir MR. Acute ingestions of thyroid hormones. Pediatrics. 1984 Mar. 73(3):313-7. [QxMD MEDLINE Link].
Mariotti S, Martino E, Cupini C, Lari R, Giani C, Baschieri L, et al. Low serum thyroglobulin as a clue to the diagnosis of thyrotoxicosis factitia. N Engl J Med. 1982 Aug 12. 307(7):410-2. [QxMD MEDLINE Link].
Seger D. Endocrine principles. Goldfrank L, ed. Goldfrank's Toxicologic Emergencies. 5th ed. New York, NY: McGraw-Hill; 1994. 338-90.
Singh GK, Winterborn MH. Massive overdose with thyroxine,--toxicity and treatment. Eur J Pediatr. 1991 Jan. 150(3):217. [QxMD MEDLINE Link].
Tunget CL, Clark RF, Turchen SG, Manoguerra AS. Raising the decontamination level for thyroid hormone ingestions. Am J Emerg Med. 1995 Jan. 13(1):9-13. [QxMD MEDLINE Link].
Lexicomp. Levothyroxine: Drug information. Available at https://www.uptodate.com/contents/levothyroxine-drug-information. Accessed: 11 March 2022.

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Author

Amanda Lu, MD Resident Physician, Department of Emergency Medicine, Naval Medical Center San Diego

Amanda Lu, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

William D Goldenberg, MD Assistant Professor, Department of Emergency Medicine, Uniformed Services University of the Health Sciences; Staff Emergency Physician, Naval Medical Center San Diego

William D Goldenberg, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents' Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine and Medical Toxicology, Excela Health System

Fred Harchelroad, MD, FACMT, FAAEM, FACEP is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Lisandro Irizarry, MD, MBA, MPH, FACEP Chair, Department of Emergency Medicine, Wyckoff Heights Medical Center

Lisandro Irizarry, MD, MBA, MPH, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Nadine A Youssef, MD Assistant Professor, Department of Emergency Medicine, Tufts University School of Medicine

Nadine A Youssef, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Anton A Wray, MD, FACEP Assistant Professor of Clinical Emergency Medicine, New York Medical College; Program Director Department of Emergency Medicine, Wyckoff Heights Medical Center

Anton A Wray, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Thyroid Hormone Toxicity Clinical Presentation

History and Physical Examination

History

Physical examination

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