History
Patients may have a known history of thyrotoxicosis. 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. Burch and Wartofsky have published precise criteria and a scoring system for the diagnosis of thyroid storm based on clinical features. [2]
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General symptoms
Fever
Profuse sweating
Poor feeding and weight loss
Respiratory distress
Fatigue (more common in older adolescents)
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GI symptoms
Nausea and vomiting
Diarrhea
Abdominal pain
Jaundice [3]
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Neurologic symptoms
Anxiety (more common in older adolescents)
Altered behavior
Seizures, coma
Physical Examination
Physical findings include the following:
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Fever
Temperature consistently exceeds 38.5°C.
Patients may progress to hyperpyrexia.
Temperature frequently exceeds 41°C.
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Excessive sweating
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Cardiovascular signs
Hypertension with wide pulse pressure
Hypotension in later stages with shock
Tachycardia disproportionate to fever
Signs of high-output heart failure
Cardiac arrhythmia (Supraventricular arrhythmias are more common, [eg, atrial flutter and fibrillation], but ventricular tachycardia may also occur.)
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Neurologic signs
Agitation and confusion
Hyperreflexia and transient pyramidal signs
Tremors, seizures
Coma
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Signs of thyrotoxicosis
Orbital signs
Goiter
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Rhabdomyolysis - Rare cases have been reported following a diagnosis of thyroid storm in adults [17]
Complications
Complications of thyroid storm include:
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High output cardiac failure
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Cardiac arrhythmias
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Delirium, seizures, coma
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Abdominal pain, diarrhea, vomiting, jaundice
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Elevation of transaminases
A study by Mohananey et al found that out of 41,835 US patients with thyroid storm, 1% developed cardiogenic shock, with the incidence of this complication in these patients rising between 2003 and 2011 from 0.5% to 3%. However, during this same period the mortality rate from cardiogenic shock in patients with thyroid storm decreased from 60.5% to 20.9%. The highest likelihood of cardiogenic shock was in male patients with preexisting atherosclerotic or structural heart disease. [18]
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Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
