Thyrotoxic Storm Following Thyroidectomy Clinical Presentation

Updated: Aug 06, 2020
  • Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Clinical features form the hallmark in diagnosing thyroid storm. Patients with a known history of thyrotoxicosis present with a classic triad of hyperthermia, tachycardia and altered mental status. Most patients have goiter, and many of those with Graves disease have concurrent ophthalmopathy. In the absence of previously diagnosed thyrotoxicosis, the history may include symptoms such as irritability, agitation, emotional lability, a voracious appetite with poor weight gain, excessive sweating and heat intolerance, and poor school performance caused by decreased attention span.


Physical Examination

An accentuation of signs and symptoms is seen in uncomplicated thyrotoxicosis. The point of transition from uncomplicated thyrotoxicosis to thyroid storm is difficult to ascertain. Very few criteria define the change. However, certain clinical features (eg, high-grade fever, mental obtundation, decompensation of one or more organ systems secondary to the severe state of hypermetabolism) herald its onset.

The table below presents some changes in the symptoms and signs of thyroid storm when compared with uncomplicated thyrotoxicosis. Importantly, some findings of thyroid storm (eg, atrial dysrhythmia) may also prevail in uncomplicated thyrotoxicosis. Therefore, the table represents only guidelines, not specific criteria to define thyroid storm.

Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis (Open Table in a new window)

Uncomplicated Thyrotoxicosis

Thyroid Storm

1. Heat intolerance, diaphoresis

1. Hyperpyrexia, temperature in excess of 38°C, dehydration

2. Sinus tachycardia, heart rate 100-140

2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure

3. Diarrhea, increased appetite with loss of weight

3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice

4. Anxiety, restlessness

4. Confusion, agitation, delirium, frank psychosis, seizures, stupor, or coma

Certain unusual presentations include chest pain, acute abdomen, status epilepticus, stroke, acute renal failure due to rhabdomyolysis, and apathetic thyroidism. Apathetic thyroidism is more frequently seen in elderly patients but has been described in all ages. Patients in this variant group present without goiter, ophthalmopathy, or prominent symptoms of hyperthyroidism. These patients have a low pulse rate and a propensity to develop thyroid storm due to delay in diagnosis.