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Thyroid storm

Thyroid storm is a rare but severe and life-threatening complication of hyperthyroidism. It occurs when overactive thyroid activity leads to hypermetabolism, the end result being death from cardiac arrest or multiple organ failure.[2]

Thyroid storm
Other namesThyrotoxic crisis
SpecialtyEndocrinology 
Differential diagnosisSepsis, infectious disease[1]
Prognosis8-25% mortality with treatment; 80-100% mortality if untreated

It is characterized by a high fever (temperatures often above 40 °C / 104 °F), fast and often irregular heart beat, elevated blood pressure, vomiting, diarrhea, and agitation. Hypertension with a wide pulse pressure occurs in early to mid crisis, with hypotension accompanying shock occurring in the late stage.[3] Heart failure and heart attack may occur. Death may occur despite treatment.[4] Most episodes occur either in those with known hyperthyroidism whose treatment has been stopped or become ineffective, or in those with untreated mild hyperthyroidism who have developed an intercurrent illness (such as an infection).[4]

The primary treatment of thyroid storm is with inorganic iodine and antithyroid drugs (propylthiouracil or methimazole) to reduce synthesis and release of thyroid hormone. Temperature control and intravenous fluids are also mainstays of management. Beta blockers are often used to reduce the effects of thyroid hormone.[5] Patients often require admission to the intensive care unit.[6]

A life-threatening medical emergency, thyroid storm has a mortality rate of up to 25% despite treatment.[1][7] Without treatment, the condition is very likely fatal, with a mortality rate of 80-100%.[8] Historically, the condition was considered untreatable, with hospital mortality rates approaching 100%.[9][10]

Signs and symptoms edit

Thyroid storm is characterized by an acute onset of symptoms of hyperthyroidism (fast heart rate, restlessness, agitation) accompanied by other features such as fever (temperatures often above 40 °C/104 °F), hypertension, mental status changes, diarrhea, and vomiting.[11]

Individuals can exhibit varying signs of organ dysfunction. Patients may experience liver dysfunction, and jaundice (yellowing of the skin), which is considered a poor prognostic sign. Cardiac (heart) symptoms include abnormal heart rhythms, myocardial infarction (heart attack), and congestive heart failure, which may lead to cardiovascular collapse. Mortality can be as high as 20–30%.[12]

In some situations, individuals may not experience the classic signs of restlessness and agitation, but instead present with apathetic signs of weakness and confusion.[11]

Causes edit

The transition from hyperthyroidism to thyroid storm is typically triggered by a non-thyroidal insult including, but not limited to fever, sepsis, dehydration, myocardial infarction, and psychiatric diseases.[vague][13][14] Individuals are at higher risk of thyroid storm if their hyperthyroidism is incompletely treated or if their anti-thyroid drugs are discontinued. Many of these individuals have underlying primary causes of hyperthyroidism (Graves' disease, toxic multi-nodular goiter, solitary toxic adenoma, or amiodarone). However, thyroid storm can occur in individuals with unrecognized thyrotoxicosis experiencing non-thyroid surgery, labor, infection, or exposure to certain medications and radiocontrast dyes.[citation needed]

Precipitating factors[11][15]
Severe infection
Diabetic ketoacidosis
Hypoglycemia
Thyroid surgery
Non-thyroid surgery
Parturition
Struma ovarii
Molar pregnancy
Trauma (i.e. hip fracture)
Burns
Myocardial infarction
Pulmonary embolism
Stroke
Heart failure
Radioactive iodine treatment
Medication side effect (anesthetics, salicylate, pseudoephedrine, amiodarone)
Exposure to iodinated contrast
Withdrawal of antithyroid treatment
Emotional stress
Intense exercise

Pathophysiology edit

 

The precise mechanism for the development of thyroid storm is poorly understood. In the human body, thyroid hormone may be free (biologically active T3/T4) or bound to thyroid binding hormone (biologically inactive) to be transported. The release of thyroid hormone is tightly regulated by a feedback system involving the hypothalamus, pituitary gland, and thyroid gland. Hyperthyroidism results from a dysregulation of this system that eventually leads to increases in levels of free T3/T4. The transition from simple hyperthyroidism to the medical emergency of thyroid storm may be triggered by conditions (see Causes) that lead to the following:

Increases in free thyroid hormone edit

Individuals with thyroid storm tend to have increased levels of free thyroid hormone, although total thyroid hormone levels may not be much higher than in uncomplicated hyperthyroidism.[15] The rise in the availability of free thyroid hormone may be the result of manipulating the thyroid gland. In the setting of an individual receiving radioactive iodine therapy, free thyroid hormone levels may acutely increase due to the release of hormone from ablated thyroid tissue.[citation needed]

Decrease in thyroid hormone binding protein edit

A decrease in thyroid hormone binding protein in the setting of various stressors or medications may also cause a rise in free thyroid hormone.[5]

Increased sensitivity to thyroid hormone edit

Along with increases in thyroid hormone availability, it is also suggested that thyroid storm is characterized by the body's heightened sensitivity to thyroid hormone, which may be related to sympathetic activation (see below).[15]

Sympathetic activation edit

Sympathetic nervous system activation during times of stress may also play a significant role in thyroid storm.[5] Sympathetic activation increases production of thyroid hormone by the thyroid gland. In the setting of elevated thyroid hormone, the density of thyroid hormone receptors (esp. beta-receptors) also increases, which enhances the response to catecholamines. This is likely responsible for several of the cardiovascular symptoms (increased cardiac output, heart rate, stroke volume) seen in thyroid storm.[citation needed][16]

Thyroid storm as allostatic failure edit

According to newer theories, thyroid storm results from allostatic failure in a situation where thyrotoxicosis hampers the development of non-thyroidal illness syndrome,[17] which would help to save energy in critical illness and other situations of high metabolic demand.[14]

Usually, in critical illness (e.g. sepsis, myocardial infarction and other causes of shock) thyroid function is tuned down to result in low-T3 syndrome and, occasionally, also low TSH concentrations, low-T4 syndrome and impaired plasma protein binding of thyroid hormones. This endocrine pattern is referred to as euthyroid sick syndrome (ESS), non-thyroidal illness syndrome (NTIS) or thyroid allostasis in critical illness, tumours, uraemia and starvation (TACITUS). Although NTIS is associated with significantly worse prognosis, it is also assumed to represent a beneficial adaptation (type 1 allostasis). In cases, where critical illness is accompanied by thyrotoxicosis, this comorbidity prevents the down-regulation of thyroid function. Therefore, the consumption of energy, oxygen and glutathione remains high, which leads to further increased mortality.[17]

These new theories imply that thyroid storm results from an interaction of thyrotoxicosis with the specific response of the organism to an oversupply of thyroid hormones.[13]

Diagnosis edit

The diagnosis of thyroid storm is based on the presence of signs and symptoms consistent with severe hyperthyroidism.[15] Multiple approaches have been proposed to calculate the probability of thyroid storm based on clinical criteria, however, none have been universally adopted by clinicians. For instance, Burch and Wartofsky published the Burch-Wartofsky point scale (BWPS) in 1993, assigning a numerical value based on the presence of specific signs and symptoms organized within the following categories: temperature, cardiovascular dysfunction (including heart rate and presence of atrial fibrillation or congestive heart failure), central nervous system (CNS) dysfunction, gastrointestinal or liver dysfunction and presence of a precipitating event.[15][18] A Burch-Wartofsky score below 25 is not suggestive of thyroid storm whereas 25 to 45 suggests impending thyroid storm and greater than 45 suggests current thyroid storm.[19] Alternatively, the Japanese Thyroid Association (JTA) criteria, derived from a large cohort of patients with thyroid storm in Japan and published in 2012, provide a qualitative method to determine the probability of thyroid storm. The JTA criteria separate the diagnosis of thyroid storm into definite versus suspected based on the specific combination of signs and symptoms a patient exhibits and require elevated free triiodothyronine (T3) or free thyroxine (T4) for definite thyroid storm.[20]

Burch-Wartofsky Point Scale[15]
Temperature Score Heart Rate Score Symptoms of Heart Failure Score Presence of Atrial Fibrillation Score Symptoms of CNS Dysfunction Score Gastrointestinal or Liver Dysfunction Score Presence of Precipitating Event Score
99.0 to 99.9 5 90 to 109 5 None 0 Absent 0 None 0 None 0 None 0
100.0 to 100.9 10 110 to 119 10 Mild (i.e. pedal edema) 5 Present 10 Mild (e.g. showing signs of agitation) 10 Moderate (e.g. diarrhea, nausea, vomiting or abdominal pain) 10 Present 10
101.0 to 101.9 15 120 to 129 15 Moderate (i.e. bibasilar rales) 10 Moderate (e.g. delirium, psychosis, lethargy) 20 Severe (i.e. unexplained jaundice) 20
102.0 to 102.9 20 130 to 139 20 Severe (i.e. pulmonary edema) 15 Severe (e.g. seizure or coma) 30
103 to 103.9 25 Greater than or equal to 140 25
Greater than or equal to 104 30

Laboratory findings edit

As with hyperthyroidism, TSH is suppressed. Both free and serum (or total) T3 and T4 are elevated.[11] An elevation in thyroid hormone levels is suggestive of thyroid storm when accompanied by signs of severe hyperthyroidism but is not diagnostic as it may also correlate with uncomplicated hyperthyroidism.[15][18] Moreover, serum T3 may be normal in critically ill patients due to decreased conversion of T4 to T3.[15] Other potential abnormalities include the following:[15][18]

Management edit

The main strategies for the management of thyroid storm are reducing production and release of thyroid hormone, reducing the effects of thyroid hormone on tissues, replacing fluid losses, and controlling temperature.[5] Thyroid storm requires prompt treatment and hospitalization. Often, admission to the intensive care unit is needed.[21] In cases of heart failure leading to hemodynamic collapse, cardiocirculatory support including VA-ECMO may be required.[22]

In high fever, temperature control is achieved with fever reducers such as paracetamol/acetaminophen and external cooling measures (cool blankets, ice packs). Dehydration, which occurs due to fluid loss from sweating, diarrhea, and vomiting, is treated with frequent fluid replacement.[21] In severe cases, mechanical ventilation may be necessary. Any suspected underlying cause is also addressed.[4]

Iodine edit

Guidelines recommend the administration of inorganic iodide (potassium iodide or Lugol's iodine[6][21]) to reduce the synthesis and release of thyroid hormone. In high dosage, iodine may reduce the synthesis of thyroid hormone via the Wolff-Chaikoff effect and its release via the Plummer effect.[5] Some guidelines recommend that iodine be administered after antithyroid medications are started, because iodine is also a substrate for the synthesis of thyroid hormone, and may worsen hyperthyroidism if administered without antithyroid medications.[5]

Antithyroid medications edit

Antithyroid drugs (propylthiouracil or methimazole) are used to reduce the synthesis and release of thyroid hormone. Propylthiouracil is preferred over methimazole due to its additional effects on reducing peripheral conversion of T4 to T3,[5] however both are commonly used. If the etiology involves subacute thyroiditis, antithyroid medications are not always used, and its use is "controversial".[23][24]

Beta blockers edit

The administration of beta-1-selective beta blockers (e.g. metoprolol) is recommended to reduce the effect of circulating thyroid hormone on end organs.[4][21][6]

Propranolol at high doses is a common first-line treatment, as it reduces peripheral conversion of T4 to T3, which is the more active form of thyroid hormone.[25][21] Non-selective beta blockers have been suggested to be beneficial due to their inhibitory effects on peripheral deiodinases. Some recent research suggests them to be associated with increased mortality.[26] Therefore, cardioselective beta blockers may be favourable.[14]

Corticosteroids edit

High levels of thyroid hormone result in a hypermetabolic state, which can result in increased breakdown of cortisol, a hormone produced by the adrenal gland. This results in a state of relative adrenal insufficiency, in which the amount of cortisol is not sufficient.[26] Guidelines recommend that corticosteroids (hydrocortisone and dexamethasone are preferred over prednisolone or methylprednisolone) be administered to all patients with thyroid storm. However, doses should be altered for each individual patient to ensure that the relative adrenal insufficiency is adequately treated while minimizing the risk of side effects.[26]

Plasmapheresis edit

Plasmapheresis removes cytokines, antibodies, and thyroid hormones from the plasma.[27] It is usually reserved for severe refractory cases of thyroid storm as a bridge to surgery.[28]

See also edit

References edit

  1. ^ a b Pokhrel, Binod; Aiman, Wajeeha; Bhusal, Kamal (2022-10-06). "Thyroid Storm". StatPearls Publishing. PMID 28846289. Retrieved 2023-05-28.
  2. ^ Nai, Qiang; Ansari, Mohammad; Pak, Stella; Tian, Yufei; Amzad-Hossain, Mohammed; Zhang, Yanhong; Lou, Yali; Sen, Shuvendu; Islam, Mohammed (2018). "Cardiorespiratory Failure in Thyroid Storm: Case Report and Literature Review". Journal of Clinical Medicine Research. Elmer Press, Inc. 10 (4): 351–357. doi:10.14740/jocmr3106w. ISSN 1918-3003. PMC 5827921. PMID 29511425.
  3. ^ "Thyroid Storm Clinical Presentation: History, Physical Examination, Complications".
  4. ^ a b c d Klubo-Gwiezdzinska, Joanna; Wartofsky, Leonard (March 2012). "Thyroid emergencies". Medical Clinics of North America. 96 (2): 385–403. doi:10.1016/j.mcna.2012.01.015. PMID 22443982.
  5. ^ a b c d e f g Chiha M, Samara S, Kabaker A (March 2015). "Thyroid Storm: An Updated Review". Journal of Intensive Care Medicine. 30 (3): 131–140. doi:10.1177/0885066613498053. PMID 23920160. S2CID 21369274.
  6. ^ a b c Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN (June 2011). "Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists". Thyroid. 21 (6): 593–646. doi:10.1089/thy.2010.0417. PMID 21510801.
  7. ^ Ono, Yosuke; Ono, Sachiko; Yasunaga, Hideo; Matsui, Hiroki; Fushimi, Kiyohide; Tanaka, Yuji (2016). "Factors Associated With Mortality of Thyroid Storm". Medicine. Ovid Technologies (Wolters Kluwer Health). 95 (7): e2848. doi:10.1097/md.0000000000002848. ISSN 0025-7974. PMC 4998648. PMID 26886648.
  8. ^ Idrose, Alzamani Mohammad (2015-05-12). "Acute and emergency care for thyrotoxicosis and thyroid storm". Acute Medicine & Surgery. Wiley. 2 (3): 147–157. doi:10.1002/ams2.104. ISSN 2052-8817. PMC 5667251. PMID 29123713.
  9. ^ "Gathering Storm: Treating the Once Fatal Thyroid Storm". Endocrine News. 2014-08-01. Retrieved 2023-05-28.
  10. ^ Misra, Madhusmita (2023-02-02). "Thyroid Storm: Practice Essentials, Pathophysiology, Etiology". Medscape Reference. Retrieved 2023-05-28.
  11. ^ a b c d Gardner DG (2017). "Endocrine Emergencies". In Gardner DG, Shoback D (eds.). Greenspan's Basic and Clinical Endocrinology (10 ed.). New York: McGraw-Hill.
  12. ^ Paulson JM, Hollenberg AN (2017). "Thyroid Emergencies". In McKean SC, Ross JJ, Dressler DD, Scheurer DB (eds.). Principles and Practice of Hospital Medicine (2 ed.). New York: McGraw-Hill. ISBN 978-0-07-184313-3.
  13. ^ a b Dietrich, JW (September 2012). "Thyreotoxische Krise [Thyroid storm]". Medizinische Klinik, Intensivmedizin und Notfallmedizin. 107 (6): 448–53. doi:10.1007/s00063-012-0113-2. PMID 22878518. S2CID 31285541.
  14. ^ a b c Dietrich, J. (15 June 2016). "Thyreotoxische Krise und Myxödemkoma". Der Nuklearmediziner. 39 (2): 124–131. doi:10.1055/s-0042-105786.
  15. ^ a b c d e f g h i Chiha, Maguy; Samarasinghe, Shanika; Kabaker, Adam S. (2013-08-05). "Thyroid Storm". Journal of Intensive Care Medicine. 30 (3): 131–140. doi:10.1177/0885066613498053. PMID 23920160. S2CID 21369274.
  16. ^ Holt, Elizabeth H.; Peery, Harry E. (28 July 2010). Basic Medical Endocrinology (4th ed.). Academic Press. pp. 52–53. ISBN 978-0-08-092055-9.
  17. ^ a b Chatzitomaris, Apostolos; Hoermann, Rudolf; Midgley, John E.; Hering, Steffen; Urban, Aline; Dietrich, Barbara; Abood, Assjana; Klein, Harald H.; Dietrich, Johannes W. (20 July 2017). "Thyroid Allostasis–Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming". Frontiers in Endocrinology. 8: 163. doi:10.3389/fendo.2017.00163. PMC 5517413. PMID 28775711.
  18. ^ a b c Klubo-Gwiezdzinska, Joanna; Wartofsky, Leonard (March 2012). "Thyroid emergencies". The Medical Clinics of North America. 96 (2): 385–403. doi:10.1016/j.mcna.2012.01.015. ISSN 1557-9859. PMID 22443982.
  19. ^ Burch, H. B.; Wartofsky, L. (June 1993). "Life-threatening thyrotoxicosis. Thyroid storm". Endocrinology and Metabolism Clinics of North America. 22 (2): 263–277. doi:10.1016/S0889-8529(18)30165-8. ISSN 0889-8529. PMID 8325286.
  20. ^ Akamizu, Takashi; Satoh, Tetsurou; Isozaki, Osamu; Suzuki, Atsushi; Wakino, Shu; Iburi, Tadao; Tsuboi, Kumiko; Monden, Tsuyoshi; Kouki, Tsuyoshi (July 2012). "Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys". Thyroid. 22 (7): 661–679. doi:10.1089/thy.2011.0334. ISSN 1557-9077. PMC 3387770. PMID 22690898.
  21. ^ a b c d e Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN (June 2011). "Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists". Thyroid. 21 (6): 593–646. doi:10.1089/thy.2010.0417. PMID 21510801.
  22. ^ Amos, Shoshana (May 2023). ""VA-ECMO for Thyroid Storm: Case Reports and Review of the Literature". Isr Med Assoc J. 25 (5): 349–350. PMID 37245101.
  23. ^ Salih, Abdulwahid M.; Kakamad, F.H.; Rawezh, Q.S.; Masrur, S.A.; Shvan, H.M.; Hawbash, M.R.; Lhun, T.H. (2017). "Subacute thyroiditis causing thyrotoxic crisis; a case report with literature review". International Journal of Surgery Case Reports. Elsevier BV. 33: 112–114. doi:10.1016/j.ijscr.2017.02.041. ISSN 2210-2612. PMC 5387892. PMID 28399492.
  24. ^ Gaballa, Salem; Hlaing, Kyaw M; Bos, Nadine; Moursy, Safa; Hakami, Mustafa (2020-07-29). "A Rare Case of Subacute Painful Thyroiditis Causing Thyroid Storm and a Successful Trial of Propylthiouracil". Cureus. Cureus, Inc. 12 (7): e9461. doi:10.7759/cureus.9461. ISSN 2168-8184. PMC 7392358. PMID 32760639.
  25. ^ Bokhari, Syed Faqeer Hussain; Sattar, Huma; Abid, Shaun; Vohra, Rimsha R; Sajid, Samar (2022-09-19). "Cardiovascular Collapse Secondary to Beta-Blocker Administration in a Setting of Coexisting Thyroid Storm and Atrial Fibrillation: A Case Report". Cureus. Cureus, Inc. 14 (9): e29321. doi:10.7759/cureus.29321. ISSN 2168-8184. PMC 9580232. PMID 36277558.
  26. ^ a b c Isozaki, O; Satoh, T; Wakino, S; Suzuki, A; Iburi, T; Tsuboi, K; Kanamoto, N; Otani, H; Furukawa, Y; Teramukai, S; Akamizu, T (June 2016). "Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm". Clinical Endocrinology. 84 (6): 912–8. doi:10.1111/cen.12949. PMID 26387649. S2CID 3050566.
  27. ^ Muller, Clotilde; Perrin, Peggy; Faller, Bernadette; Richter, Sarah; Chantrel, Francois (December 2011). "Role of plasma exchange in the thyroid storm". Therapeutic Apheresis and Dialysis. 15 (6): 522–531. doi:10.1111/j.1744-9987.2011.01003.x. ISSN 1744-9987. PMID 22107688. S2CID 22810551.
  28. ^ Tieken, Kelsey; Paramasivan, Ameena Madan; Goldner, Whitney; Yuil-Valdes, Ana; Fingeret, Abbey L. (January 2020). "Therapeutic Plasma Exchange as a Bridge to Total Thyroidectomy in Patients with Severe Thyrotoxicosis". AACE Clinical Case Reports. 6 (1): e14–e18. doi:10.4158/ACCR-2019-0132. ISSN 2376-0605. PMC 7279771. PMID 32984516.

External links edit

thyroid, storm, rare, severe, life, threatening, complication, hyperthyroidism, occurs, when, overactive, thyroid, activity, leads, hypermetabolism, result, being, death, from, cardiac, arrest, multiple, organ, failure, other, namesthyrotoxic, crisisspecialtye. Thyroid storm is a rare but severe and life threatening complication of hyperthyroidism It occurs when overactive thyroid activity leads to hypermetabolism the end result being death from cardiac arrest or multiple organ failure 2 Thyroid stormOther namesThyrotoxic crisisSpecialtyEndocrinology Differential diagnosisSepsis infectious disease 1 Prognosis8 25 mortality with treatment 80 100 mortality if untreatedIt is characterized by a high fever temperatures often above 40 C 104 F fast and often irregular heart beat elevated blood pressure vomiting diarrhea and agitation Hypertension with a wide pulse pressure occurs in early to mid crisis with hypotension accompanying shock occurring in the late stage 3 Heart failure and heart attack may occur Death may occur despite treatment 4 Most episodes occur either in those with known hyperthyroidism whose treatment has been stopped or become ineffective or in those with untreated mild hyperthyroidism who have developed an intercurrent illness such as an infection 4 The primary treatment of thyroid storm is with inorganic iodine and antithyroid drugs propylthiouracil or methimazole to reduce synthesis and release of thyroid hormone Temperature control and intravenous fluids are also mainstays of management Beta blockers are often used to reduce the effects of thyroid hormone 5 Patients often require admission to the intensive care unit 6 A life threatening medical emergency thyroid storm has a mortality rate of up to 25 despite treatment 1 7 Without treatment the condition is very likely fatal with a mortality rate of 80 100 8 Historically the condition was considered untreatable with hospital mortality rates approaching 100 9 10 Contents 1 Signs and symptoms 2 Causes 3 Pathophysiology 3 1 Increases in free thyroid hormone 3 2 Decrease in thyroid hormone binding protein 3 3 Increased sensitivity to thyroid hormone 3 4 Sympathetic activation 3 5 Thyroid storm as allostatic failure 4 Diagnosis 4 1 Laboratory findings 5 Management 5 1 Iodine 5 2 Antithyroid medications 5 3 Beta blockers 5 4 Corticosteroids 5 5 Plasmapheresis 6 See also 7 References 8 External linksSigns and symptoms editThyroid storm is characterized by an acute onset of symptoms of hyperthyroidism fast heart rate restlessness agitation accompanied by other features such as fever temperatures often above 40 C 104 F hypertension mental status changes diarrhea and vomiting 11 Individuals can exhibit varying signs of organ dysfunction Patients may experience liver dysfunction and jaundice yellowing of the skin which is considered a poor prognostic sign Cardiac heart symptoms include abnormal heart rhythms myocardial infarction heart attack and congestive heart failure which may lead to cardiovascular collapse Mortality can be as high as 20 30 12 In some situations individuals may not experience the classic signs of restlessness and agitation but instead present with apathetic signs of weakness and confusion 11 Causes editThe transition from hyperthyroidism to thyroid storm is typically triggered by a non thyroidal insult including but not limited to fever sepsis dehydration myocardial infarction and psychiatric diseases vague 13 14 Individuals are at higher risk of thyroid storm if their hyperthyroidism is incompletely treated or if their anti thyroid drugs are discontinued Many of these individuals have underlying primary causes of hyperthyroidism Graves disease toxic multi nodular goiter solitary toxic adenoma or amiodarone However thyroid storm can occur in individuals with unrecognized thyrotoxicosis experiencing non thyroid surgery labor infection or exposure to certain medications and radiocontrast dyes citation needed Precipitating factors 11 15 Severe infectionDiabetic ketoacidosisHypoglycemiaThyroid surgeryNon thyroid surgeryParturitionStruma ovariiMolar pregnancyTrauma i e hip fracture BurnsMyocardial infarctionPulmonary embolismStrokeHeart failureRadioactive iodine treatmentMedication side effect anesthetics salicylate pseudoephedrine amiodarone Exposure to iodinated contrastWithdrawal of antithyroid treatmentEmotional stressIntense exercisePathophysiology edit nbsp The precise mechanism for the development of thyroid storm is poorly understood In the human body thyroid hormone may be free biologically active T3 T4 or bound to thyroid binding hormone biologically inactive to be transported The release of thyroid hormone is tightly regulated by a feedback system involving the hypothalamus pituitary gland and thyroid gland Hyperthyroidism results from a dysregulation of this system that eventually leads to increases in levels of free T3 T4 The transition from simple hyperthyroidism to the medical emergency of thyroid storm may be triggered by conditions see Causes that lead to the following Increases in free thyroid hormone edit Individuals with thyroid storm tend to have increased levels of free thyroid hormone although total thyroid hormone levels may not be much higher than in uncomplicated hyperthyroidism 15 The rise in the availability of free thyroid hormone may be the result of manipulating the thyroid gland In the setting of an individual receiving radioactive iodine therapy free thyroid hormone levels may acutely increase due to the release of hormone from ablated thyroid tissue citation needed Decrease in thyroid hormone binding protein edit A decrease in thyroid hormone binding protein in the setting of various stressors or medications may also cause a rise in free thyroid hormone 5 Increased sensitivity to thyroid hormone edit Along with increases in thyroid hormone availability it is also suggested that thyroid storm is characterized by the body s heightened sensitivity to thyroid hormone which may be related to sympathetic activation see below 15 Sympathetic activation edit Sympathetic nervous system activation during times of stress may also play a significant role in thyroid storm 5 Sympathetic activation increases production of thyroid hormone by the thyroid gland In the setting of elevated thyroid hormone the density of thyroid hormone receptors esp beta receptors also increases which enhances the response to catecholamines This is likely responsible for several of the cardiovascular symptoms increased cardiac output heart rate stroke volume seen in thyroid storm citation needed 16 Thyroid storm as allostatic failure edit According to newer theories thyroid storm results from allostatic failure in a situation where thyrotoxicosis hampers the development of non thyroidal illness syndrome 17 which would help to save energy in critical illness and other situations of high metabolic demand 14 Usually in critical illness e g sepsis myocardial infarction and other causes of shock thyroid function is tuned down to result in low T3 syndrome and occasionally also low TSH concentrations low T4 syndrome and impaired plasma protein binding of thyroid hormones This endocrine pattern is referred to as euthyroid sick syndrome ESS non thyroidal illness syndrome NTIS or thyroid allostasis in critical illness tumours uraemia and starvation TACITUS Although NTIS is associated with significantly worse prognosis it is also assumed to represent a beneficial adaptation type 1 allostasis In cases where critical illness is accompanied by thyrotoxicosis this comorbidity prevents the down regulation of thyroid function Therefore the consumption of energy oxygen and glutathione remains high which leads to further increased mortality 17 These new theories imply that thyroid storm results from an interaction of thyrotoxicosis with the specific response of the organism to an oversupply of thyroid hormones 13 Diagnosis editThe diagnosis of thyroid storm is based on the presence of signs and symptoms consistent with severe hyperthyroidism 15 Multiple approaches have been proposed to calculate the probability of thyroid storm based on clinical criteria however none have been universally adopted by clinicians For instance Burch and Wartofsky published the Burch Wartofsky point scale BWPS in 1993 assigning a numerical value based on the presence of specific signs and symptoms organized within the following categories temperature cardiovascular dysfunction including heart rate and presence of atrial fibrillation or congestive heart failure central nervous system CNS dysfunction gastrointestinal or liver dysfunction and presence of a precipitating event 15 18 A Burch Wartofsky score below 25 is not suggestive of thyroid storm whereas 25 to 45 suggests impending thyroid storm and greater than 45 suggests current thyroid storm 19 Alternatively the Japanese Thyroid Association JTA criteria derived from a large cohort of patients with thyroid storm in Japan and published in 2012 provide a qualitative method to determine the probability of thyroid storm The JTA criteria separate the diagnosis of thyroid storm into definite versus suspected based on the specific combination of signs and symptoms a patient exhibits and require elevated free triiodothyronine T3 or free thyroxine T4 for definite thyroid storm 20 Burch Wartofsky Point Scale 15 Temperature Score Heart Rate Score Symptoms of Heart Failure Score Presence of Atrial Fibrillation Score Symptoms of CNS Dysfunction Score Gastrointestinal or Liver Dysfunction Score Presence of Precipitating Event Score99 0 to 99 9 5 90 to 109 5 None 0 Absent 0 None 0 None 0 None 0100 0 to 100 9 10 110 to 119 10 Mild i e pedal edema 5 Present 10 Mild e g showing signs of agitation 10 Moderate e g diarrhea nausea vomiting or abdominal pain 10 Present 10101 0 to 101 9 15 120 to 129 15 Moderate i e bibasilar rales 10 Moderate e g delirium psychosis lethargy 20 Severe i e unexplained jaundice 20102 0 to 102 9 20 130 to 139 20 Severe i e pulmonary edema 15 Severe e g seizure or coma 30103 to 103 9 25 Greater than or equal to 140 25Greater than or equal to 104 30Laboratory findings edit As with hyperthyroidism TSH is suppressed Both free and serum or total T3 and T4 are elevated 11 An elevation in thyroid hormone levels is suggestive of thyroid storm when accompanied by signs of severe hyperthyroidism but is not diagnostic as it may also correlate with uncomplicated hyperthyroidism 15 18 Moreover serum T3 may be normal in critically ill patients due to decreased conversion of T4 to T3 15 Other potential abnormalities include the following 15 18 Hyperglycemia likely due to catecholamine mediated effects on insulin release and metabolism as well as increased glycogenolysis evolving into hypoglycemia when glycogen stores are depleted Elevated aspartate aminotransferase AST bilirubin and lactate dehydrogenase LDH Hypercalcemia and elevated alkaline phosphatase due to increased bone resorption Elevated white blood cell countManagement editThe main strategies for the management of thyroid storm are reducing production and release of thyroid hormone reducing the effects of thyroid hormone on tissues replacing fluid losses and controlling temperature 5 Thyroid storm requires prompt treatment and hospitalization Often admission to the intensive care unit is needed 21 In cases of heart failure leading to hemodynamic collapse cardiocirculatory support including VA ECMO may be required 22 In high fever temperature control is achieved with fever reducers such as paracetamol acetaminophen and external cooling measures cool blankets ice packs Dehydration which occurs due to fluid loss from sweating diarrhea and vomiting is treated with frequent fluid replacement 21 In severe cases mechanical ventilation may be necessary Any suspected underlying cause is also addressed 4 Iodine edit Guidelines recommend the administration of inorganic iodide potassium iodide or Lugol s iodine 6 21 to reduce the synthesis and release of thyroid hormone In high dosage iodine may reduce the synthesis of thyroid hormone via the Wolff Chaikoff effect and its release via the Plummer effect 5 Some guidelines recommend that iodine be administered after antithyroid medications are started because iodine is also a substrate for the synthesis of thyroid hormone and may worsen hyperthyroidism if administered without antithyroid medications 5 Antithyroid medications edit Antithyroid drugs propylthiouracil or methimazole are used to reduce the synthesis and release of thyroid hormone Propylthiouracil is preferred over methimazole due to its additional effects on reducing peripheral conversion of T4 to T3 5 however both are commonly used If the etiology involves subacute thyroiditis antithyroid medications are not always used and its use is controversial 23 24 Beta blockers edit The administration of beta 1 selective beta blockers e g metoprolol is recommended to reduce the effect of circulating thyroid hormone on end organs 4 21 6 Propranolol at high doses is a common first line treatment as it reduces peripheral conversion of T4 to T3 which is the more active form of thyroid hormone 25 21 Non selective beta blockers have been suggested to be beneficial due to their inhibitory effects on peripheral deiodinases Some recent research suggests them to be associated with increased mortality 26 Therefore cardioselective beta blockers may be favourable 14 Corticosteroids edit High levels of thyroid hormone result in a hypermetabolic state which can result in increased breakdown of cortisol a hormone produced by the adrenal gland This results in a state of relative adrenal insufficiency in which the amount of cortisol is not sufficient 26 Guidelines recommend that corticosteroids hydrocortisone and dexamethasone are preferred over prednisolone or methylprednisolone be administered to all patients with thyroid storm However doses should be altered for each individual patient to ensure that the relative adrenal insufficiency is adequately treated while minimizing the risk of side effects 26 Plasmapheresis edit Plasmapheresis removes cytokines antibodies and thyroid hormones from the plasma 27 It is usually reserved for severe refractory cases of thyroid storm as a bridge to surgery 28 See also editMyxedema coma Euthyroid sick syndromeReferences edit a b Pokhrel Binod Aiman Wajeeha Bhusal Kamal 2022 10 06 Thyroid Storm StatPearls Publishing PMID 28846289 Retrieved 2023 05 28 Nai Qiang Ansari Mohammad Pak Stella Tian Yufei Amzad Hossain Mohammed Zhang Yanhong Lou Yali Sen Shuvendu Islam Mohammed 2018 Cardiorespiratory Failure in Thyroid Storm Case Report and Literature Review Journal of Clinical Medicine Research Elmer Press Inc 10 4 351 357 doi 10 14740 jocmr3106w ISSN 1918 3003 PMC 5827921 PMID 29511425 Thyroid Storm Clinical Presentation History Physical Examination Complications a b c d Klubo Gwiezdzinska Joanna Wartofsky Leonard March 2012 Thyroid emergencies Medical Clinics of North America 96 2 385 403 doi 10 1016 j mcna 2012 01 015 PMID 22443982 a b c d e f g Chiha M Samara S Kabaker A March 2015 Thyroid Storm An Updated Review Journal of Intensive Care Medicine 30 3 131 140 doi 10 1177 0885066613498053 PMID 23920160 S2CID 21369274 a b c Bahn RS Burch HB Cooper DS Garber JR Greenlee MC Klein I Laurberg P McDougall IR Montori VM Rivkees SA Ross DS Sosa JA Stan MN June 2011 Hyperthyroidism and other causes of thyrotoxicosis management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists Thyroid 21 6 593 646 doi 10 1089 thy 2010 0417 PMID 21510801 Ono Yosuke Ono Sachiko Yasunaga Hideo Matsui Hiroki Fushimi Kiyohide Tanaka Yuji 2016 Factors Associated With Mortality of Thyroid Storm Medicine Ovid Technologies Wolters Kluwer Health 95 7 e2848 doi 10 1097 md 0000000000002848 ISSN 0025 7974 PMC 4998648 PMID 26886648 Idrose Alzamani Mohammad 2015 05 12 Acute and emergency care for thyrotoxicosis and thyroid storm Acute Medicine amp Surgery Wiley 2 3 147 157 doi 10 1002 ams2 104 ISSN 2052 8817 PMC 5667251 PMID 29123713 Gathering Storm Treating the Once Fatal Thyroid Storm Endocrine News 2014 08 01 Retrieved 2023 05 28 Misra Madhusmita 2023 02 02 Thyroid Storm Practice Essentials Pathophysiology Etiology Medscape Reference Retrieved 2023 05 28 a b c d Gardner DG 2017 Endocrine Emergencies In Gardner DG Shoback D eds Greenspan s Basic and Clinical Endocrinology 10 ed New York McGraw Hill Paulson JM Hollenberg AN 2017 Thyroid Emergencies In McKean SC Ross JJ Dressler DD Scheurer DB eds Principles and Practice of Hospital Medicine 2 ed New York McGraw Hill ISBN 978 0 07 184313 3 a b Dietrich JW September 2012 Thyreotoxische Krise Thyroid storm Medizinische Klinik Intensivmedizin und Notfallmedizin 107 6 448 53 doi 10 1007 s00063 012 0113 2 PMID 22878518 S2CID 31285541 a b c Dietrich J 15 June 2016 Thyreotoxische Krise und Myxodemkoma Der Nuklearmediziner 39 2 124 131 doi 10 1055 s 0042 105786 a b c d e f g h i Chiha Maguy Samarasinghe Shanika Kabaker Adam S 2013 08 05 Thyroid Storm Journal of Intensive Care Medicine 30 3 131 140 doi 10 1177 0885066613498053 PMID 23920160 S2CID 21369274 Holt Elizabeth H Peery Harry E 28 July 2010 Basic Medical Endocrinology 4th ed Academic Press pp 52 53 ISBN 978 0 08 092055 9 a b Chatzitomaris Apostolos Hoermann Rudolf Midgley John E Hering Steffen Urban Aline Dietrich Barbara Abood Assjana Klein Harald H Dietrich Johannes W 20 July 2017 Thyroid Allostasis Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain Stress and Developmental Programming Frontiers in Endocrinology 8 163 doi 10 3389 fendo 2017 00163 PMC 5517413 PMID 28775711 a b c Klubo Gwiezdzinska Joanna Wartofsky Leonard March 2012 Thyroid emergencies The Medical Clinics of North America 96 2 385 403 doi 10 1016 j mcna 2012 01 015 ISSN 1557 9859 PMID 22443982 Burch H B Wartofsky L June 1993 Life threatening thyrotoxicosis Thyroid storm Endocrinology and Metabolism Clinics of North America 22 2 263 277 doi 10 1016 S0889 8529 18 30165 8 ISSN 0889 8529 PMID 8325286 Akamizu Takashi Satoh Tetsurou Isozaki Osamu Suzuki Atsushi Wakino Shu Iburi Tadao Tsuboi Kumiko Monden Tsuyoshi Kouki Tsuyoshi July 2012 Diagnostic criteria clinical features and incidence of thyroid storm based on nationwide surveys Thyroid 22 7 661 679 doi 10 1089 thy 2011 0334 ISSN 1557 9077 PMC 3387770 PMID 22690898 a b c d e Bahn RS Burch HB Cooper DS Garber JR Greenlee MC Klein I Laurberg P McDougall IR Montori VM Rivkees SA Ross DS Sosa JA Stan MN June 2011 Hyperthyroidism and other causes of thyrotoxicosis management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists Thyroid 21 6 593 646 doi 10 1089 thy 2010 0417 PMID 21510801 Amos Shoshana May 2023 VA ECMO for Thyroid Storm Case Reports and Review of the Literature Isr Med Assoc J 25 5 349 350 PMID 37245101 Salih Abdulwahid M Kakamad F H Rawezh Q S Masrur S A Shvan H M Hawbash M R Lhun T H 2017 Subacute thyroiditis causing thyrotoxic crisis a case report with literature review International Journal of Surgery Case Reports Elsevier BV 33 112 114 doi 10 1016 j ijscr 2017 02 041 ISSN 2210 2612 PMC 5387892 PMID 28399492 Gaballa Salem Hlaing Kyaw M Bos Nadine Moursy Safa Hakami Mustafa 2020 07 29 A Rare Case of Subacute Painful Thyroiditis Causing Thyroid Storm and a Successful Trial of Propylthiouracil Cureus Cureus Inc 12 7 e9461 doi 10 7759 cureus 9461 ISSN 2168 8184 PMC 7392358 PMID 32760639 Bokhari Syed Faqeer Hussain Sattar Huma Abid Shaun Vohra Rimsha R Sajid Samar 2022 09 19 Cardiovascular Collapse Secondary to Beta Blocker Administration in a Setting of Coexisting Thyroid Storm and Atrial Fibrillation A Case Report Cureus Cureus Inc 14 9 e29321 doi 10 7759 cureus 29321 ISSN 2168 8184 PMC 9580232 PMID 36277558 a b c Isozaki O Satoh T Wakino S Suzuki A Iburi T Tsuboi K Kanamoto N Otani H Furukawa Y Teramukai S Akamizu T June 2016 Treatment and management of thyroid storm analysis of the nationwide surveys The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm Clinical Endocrinology 84 6 912 8 doi 10 1111 cen 12949 PMID 26387649 S2CID 3050566 Muller Clotilde Perrin Peggy Faller Bernadette Richter Sarah Chantrel Francois December 2011 Role of plasma exchange in the thyroid storm Therapeutic Apheresis and Dialysis 15 6 522 531 doi 10 1111 j 1744 9987 2011 01003 x ISSN 1744 9987 PMID 22107688 S2CID 22810551 Tieken Kelsey Paramasivan Ameena Madan Goldner Whitney Yuil Valdes Ana Fingeret Abbey L January 2020 Therapeutic Plasma Exchange as a Bridge to Total Thyroidectomy in Patients with Severe Thyrotoxicosis AACE Clinical Case Reports 6 1 e14 e18 doi 10 4158 ACCR 2019 0132 ISSN 2376 0605 PMC 7279771 PMID 32984516 External links edit Retrieved from https en wikipedia org w index php title Thyroid storm amp oldid 1181267265, wikipedia, wiki, book, books, library,

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