Thyroid Storm Key Points

• Unrecognized thyroid storm has mortality as high as 75%.

• Thyroid storm is usually the result of another disorder that unmasks a preexisting but unidentified hyperthyroid state.

• Thyroid storm is a clinical diagnosis not defined by levels of TSH, T4, or T3.

• Suspicion of thyroid storm is a medical emergency with close monitoring (ICU) and appropriate consultation (endocrinologist).

Thyroid storm is a severe variant of thyrotoxicosis in which the metabolic state is sufficiently increased such that organ system failure can occur. It represents a rare complication of thyrotoxicosis and has a mortality rate as high as 75%, depending on how quickly it is recognized and treated (Tiegens and Leinung, 1995; Trzepacz et al., 1989; Wartofsky, 2005). Diagnosis of thyroid storm is based on clinical findings, not measured levels of circulating T4 or sTSH. Thyroid storm is often precipitated by infection, which can cause symptoms that mask a thyrotoxic state. Clinical findings in thyroid storm include hyperpyrexia (>38.8° C [102° F]), tachycardia out of proportion to temperature, gastrointestinal (GI) dysfunction (nausea, vomiting, diarrhea, jaundice), and CNS dysfunction (marked hyperirritability, anxiety, confusion, apathy, coma) (Wartofsky, 2005). There is usually pronounced decompensation of one or more organ systems. Any patient presenting with goiter, fever, and marked tachycardia should be considered to be in thyroid storm and treated accordingly. Admission to the MICU and consultation with an endocrinologist is appropriate.

Treatment of thyroid storm includes beta blockers, anti-thyroid drugs, antipyretics, aggressive fluid replacement, and identification and treatment of any precipitating process. For patients with severe symptoms, Lugol's solution or potassium iodide (SSKI) will help inhibit release of T4 into the peripheral circulation. If either is used, it should only be given after loading doses of antithyroid drugs, to block iodine-induced synthesis of T4. Lithium also has an antithy-roid effect and can be used in severe cases of thyroid storm. Severe thyrotoxic symptoms, unresponsive to all these regimens, may respond to sodium ipodate at 500 mg/day.

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