Hyperthyroid Storm

Hyperthyroid Storm – What is Thyroid Storm ? Symptoms and Treatment

Hyperthyroid Storm or Thyroid Storm, Thyrotoxic Storm, Accelerated Hyperthyroidism, Thyroid Crisis or Thyrotoxic Crisis is a very fatal hyper-metabolic condition that results from too much downpour of thyroid hormones (THs) seen in patients suffering from Hyperthyroidism of Thyrotoxicosis. This condition is very acute and develops if hyperthyroidism is left untreated. This condition is distinguished by an exaggeration of the regular clinical presentation of hyperthyroidism. Although rare, this can advance in patients with untreated hyperthyroidism which has been left untreated for some time; it is often triggered by sudden bouts of trauma, thyroid or non-thyroid surgery, infections, acute iodine load, or giving birth. The onset of suitable preoperative preparation for patients who will be undergoing thyroidectomy due to hyperthyroidism reduced the occurrence of surgically-induced thyroid storms.

Must Read: Best Home Remedies for Thyroid

Signs and Symptoms of Hyperthyroid Storm

If you look at the history of a patient suffering from a hyperthyroid storm or thyroid storm, the patient may have existing events or bouts of hyperthyroidism.

Clinical Features of Hyperthyroid Storm:

General Symptoms:

  1. Increased body temperature
  2. Shaking
  3. Dehydration
  4. Polyuria
  5. Polydipsia
  6. Amenorrhea
  7. Loss of libido
  8. Apathy
  9. Osteoporosis
  10. Palpitation
  11. Decreased appetite and weight loss
  12. Respiratory distress
  13. Restlessness
  14. Fatigue

Gastrointestinal Symptoms

  1. Abdominal pain
  2. Jaundice
  3. Diarrhea
  4. Nausea and vomiting

Neurologic Symptoms

  1. Confusion
  2. Irritability
  3. Myopathy
  4. Changes in alertness
  5. Anxiety
  6. Extreme mood swings
  7. Exaggerated reflexes
  8. Seizures
  9. Coma

Physical Findings (Based on Burch and Wartofsky studies):

  1. Fever
  2. Body temperature may exceed 41°C
  3. Excessive sweating

Cardiovascular Signs

  1. Chest pains
  2. Hypertension (with wide pulse pressure)
  3. Hypotension (seen in later stages associated with shock)
  4. Tachycardia due to fever (as high as 200 beats per minute)
  5. Signs of high-output heart failure
  6. Cardiac arrhythmia (more commonly Supraventricular arrhythmias i.e., Atrial Flutter and Atrial Fibrillation)

Neurologic Signs

  1. Confusion
  2. Agitation
  3. Tremors
  4. Chorea
  5. Periodic paralysis
  6. Seizures
  7. Coma
  8. Death

Signs of Thyrotoxicosis

  1. Goiter
  2. Orbital signs

Pathophysiology

Although the exact and direct mechanism of how hyperthyroid storm starts is not yet fully identified, there have been many theories suggested by health experts and researchers. These include the following theories:

  1. Those patients suffering from thyroid storm seemed to have rather greater levels of free thyroid hormones compared to those patients who have uncomplicated thyrotoxicosis, however, the sum of thyroid hormones levels might not go up.
  2. Another conclusion would say that activation of the adrenergic receptors might play a part in triggering thyroid storm. Also, it states that the sympathetic nerves that innervate the thyroid gland, and also catecholamine, activate the production of thyroid hormones. Thus, higher thyroid hormones levels increase the bulk of β-adrenergic receptors, allowing increased binding effect to catecholamine.
  3. The next theory proposed that a sudden surge and changes in thyroid hormone levels as one of the sources of the disorder. A sudden decrease in the levels of protein binders, which can arise after surgery, can result in sudden increase of free hormone levels.
  4. Other health theorists and researchers also suggests that changes in thyroid hormones sensitivity to tissues, the abundance of a rare catecholamine-like matter in thyrotoxicosis, plus a fix sympathomimetic outcome of thyroid hormone being the result of its structural alikeness to catecholamine.

Must Read: Dr Oz Thyroid Treatment Discussions – Natural Ways to Treat Hypothyroidism

Conclusion:

Patients who are more prone to suffering hyperthyroid storm involve much greater susceptibility to catecholamine. It is, then generalized, that in the event of too much stress (excess production of catecholamine in the body), and there is an increased risk of thyroid storm which can be fatal!

Hyperthyroid Storm Diagnostic Criteria

The diagnosis of hyperthyroid storm is not based on laboratory test findings but basically on the patient’s signs and symptoms that correlate to the clinical features of thyroid storm.

  1. Thyroid Tests
  2. Complete Blood Count (CBC)
  3. Liver Functions Tests (LFTs)
  4. Arterial Blood Gas (ABG)
  5. Urinalysis
  6. Blood Sugar Levels
  7. Imaging Studies:
  8. Chest X-Ray
  9. Computed Tomography Scan (CT scan)
  10. Other suggested tests:
  11. ECG (Electrocardiogram)
  12. Proposed Diagnostic Criteria for Thyroid Storm by Burch and Wartofsky:
  13. A score of 45 is highly suggestive of thyroid storm.
  14. A score of 25 to 44 supports the diagnosis of thyroid storm.
  15. A score below 25 renders the diagnosis of thyroid storm unlikely.

Adapted from Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263.

Treatment and Management

In order to treat and manage thyroid storm, it should include a range of medicines that will act and help the suppression of the peripheral effects of thyroid hormone, suppression thyroid hormone production and its release systemically

Medication Summary

Anthithyroids

Propylthiouracil (PTU)

  1. Conditions of Use: First line therapy
  2. Mechanism of Action: The drug of choice for thyroid storm which acts to reduce the production of thyroid hormone by preventing the organification and conversion of iodide to iodine and also by reducing the coupling of iodotyrosines.
  3. Dosage: 200-400 mg per orem every 6-8 hours

Methimazole (Tapazole)

  1. Conditions of Use: First line therapy
  2. Mechanism of Action: Acts to inhibit the production of thyroid hormones by preventing the organification and conversion of iodide to iodine and also by reducing the coupling of iodotyrosines.
  3. Dosage: 20-25 mg per orem 6 hours

Iodides

  1. Potassium Iodide
  2. Conditions of Use: Administered at least an hour after the administration of thionamide
  3. Mechanism of Action: It acts to prevent the release of thyroid hormones from the thyroid gland.
  4. Dosage: 5 drops orally every 6 hours
  5. Strong Iodine (Lugol’s Solution)
  6. Conditions of Use: Administered at least an hour after the administration of thionamide
  7. Mechanism of Action: It acts to prevent the release of thyroid hormones from the thyroid gland.
  8. Dosage: 4-8 drops orally every 6-8 hours

β Blockers

Propranolol

  1. Conditions of Use: Non-selective β-adrenergic antagonist
  2. Mechanism of Action: Acts by diminishing heart rate, contraction of heart muscles, blood pressure, and oxygen demand of heart muscles.
  3. Dosage: 60-80mg orally every 4 hours or 80-120mg every 6 hours

Atenolol

  1. Conditions of Use: This drug is prescribed when cardioselective drug is preferred over non-selective β-adrenergic blockers.
  2. Mechanism of Action: Prevent the conversion of T4 to T3.
  3. Dosage: 50-200mg orally every 24 hours

Metoprolol

  1. Conditions of Use: This drug is prescribed when cardioselective drug is preferred over non-selective β-adrenergic blockers.
  2. Mechanism of Action: Acts to prevent the conversion of T4 to T3.
  3. Dosage: 100-200mg via oral route every 24 hours

Nadolol

  1. Conditions of Use: This drug is prescribed when cardioselective drug is preferred over non-selective β-adrenergic blockers.
  2. Mechanism of Action: Acts to prevent the conversion of T4 to T3.
  3. Dosage: 40-80mg via oral route every 24 hours

Esmolol (Brevibloc)

  1. Conditions of Use: This drug is the drug of choice when drugs that are ingested orally are contraindicated or not tolerated by the patient. Mechanism of Action: This drug is β-1 specific antagonist that has a short span of its function.
  2. Dosage: 50–100µg per kg per minute via intravenous lines.

Glucocorticoids

Hydrocortisone (Solu-Cortef)

  1. Conditions of Use: Thus drug is administered when the patient is hypotensive. It is also prescribed to cure potential or probable coexisting adrenal insufficiency.
  2. Mechanism of Action: This drug is used in thyroid storm therapy to the conversion of T4 to T3.
  3. Dosage: 100 mg IV every 8 hours

Thyroid storm can also be managed operatively. There are instances when hyperthyroidism is uncontrolled and the patient’s body is no longer responding to medication or when the patient cannot tolerate any of the medications, total removal of the thyroid gland is suggested. In the case of a thyroid storm, surgery is emergent and time is very important. Thyroid hormone levels should be lowered rapidly before surgery can even begin. If the preparation for surgery is adequate, morbidity and mortality caused by thyroid surgery are very unlikely or very low.

Complications

In the present time, complications related to thyroid storm are no longer seen on patients because of the wide array of treatments that the advent of technology and research provides. However, if hyperthyroidism and other factors precipitating the occurrence of thyroid storm are not treated and detected, complications such as congestive heart failure, pulmonary edema, respiratory collapse, and end-organ damage can arise and will eventually rapidly develop and lead to death.

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