Thyrotoxic Storm Following Thyroidectomy Clinical Presentation

Updated: Jan 21, 2015
  • Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Presentation

History

Clinical features form the hallmark in diagnosing thyroid storm. Most patients have goiter, and many of those with Graves disease have concurrent ophthalmopathy. Frequently, a past history of thyroid disease that has been partially treated exists.

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Physical

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 106o 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. Lahey first described apathetic thyroidism (ie, masked hyperthyroidism) 60 years ago. [1] Apathetic thyroidism more frequently was seen in elderly patients but since 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.

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Causes

A precipitating factor usually is found with thyroid storm. Presently, the most common cause of thyroid storm is intercurrent illness or infection (ie, medical storm). [2, 3]

Some causes that rapidly increase the thyroid hormone levels include the following:

  • Surgery, thyroidal or nonthyroidal

  • Radioiodine therapy

  • Withdrawal of antithyroid drug therapy

  • Vigorous thyroid palpation

  • Iodinated contrast dye

  • Thyroid hormone ingestion

Other common precipitants include the following:

  • Infection

  • Emotional stress

  • Tooth extraction

  • Diabetic ketoacidosis

  • Hypoglycemia

  • Trauma

  • Bowel infarction

  • Parturition

  • Toxemia of pregnancy

  • Pulmonary embolism

  • Cerebrovascular accident

  • Gestational trophoblastic disease

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