What is Thyroid Storm?
Thyroid storm, also called thyrotoxic crisis, is a serious and sudden complication of a condition known as hyperthyroidism, where the thyroid gland produces too much thyroid hormone. It’s like a severe version of hyperthyroidism and can affect multiple body systems all at once. Despite advances in treatment and supportive care, the risk of death from a thyroid storm ranges from 8% to 25%. That’s why it’s incredibly vital to identify this condition early and begin intense treatment promptly to decrease the chance of death. Diagnosing a thyroid storm is based on observed symptoms and clinical assessment.
What Causes Thyroid Storm?
A thyroid storm can happen if someone has a condition called hyperthyroidism, which is when the thyroid gland is overactive. This issue is most often seen in people with a disease called Graves’ disease, but it can also happen with other overactive thyroid conditions like toxic multinodular goiter (an enlarged thyroid gland with several nodules) and toxic thyroid adenoma (a non-cancerous growth in the thyroid gland).
The likelihood of a thyroid storm increases if certain things happen. These can include:
- Stopping thyroid medication suddenly
- Having surgery on the thyroid
- Having surgery not related to the thyroid
- Experiencing physical trauma
- Falling ill suddenly with conditions like infections, including COVID-19, diabetic ketoacidosis (a serious diabetes complication), a heart attack, a stroke, heart failure, or having drug reactions
- Giving birth
- Recently using a type of medical dye called an Iodinated contrast medium
- Receiving a specific type of treatment for overactive thyroid called radioiodine therapy (although this is rare)
- Having a burn injury
- Having a stroke or a traumatic brain injury
Medications like amiodarone (heart medication), anesthetics (used for pain relief and sleep during surgery), or salicylates (used for pain, fever, inflammation) can also trigger a thyroid storm. Another trigger can be Hyperemesis gravidarum, which is severe nausea and vomiting during pregnancy.
Risk Factors and Frequency for Thyroid Storm
Thyroid storm, a severe form of hyperthyroidism, is rare. It accounts for roughly 1-2% of hyperthyroidism-related hospital admissions. In the United States, it affects 0.57 to 0.76 out of every 100,000 people annually among the general population, and 4.8 to 5.6 out of every 100,000 hospitalized patients each year.
In a Japanese survey, it was found that thyroid storm affects about 0.2 out of every 100,000 people each year, about 0.22% of all patients with thyrotoxicosis (an excess of thyroid hormone in the body), and 5.4% of the hospitalized patients with this condition. Those affected by thyroid storm are typically between 42 and 43 years old. The gender distribution is approximately three females for every male, which is also consistent with the broader patient population of thyrotoxicosis.
- Thyroid storm is a severe form of hyperthyroidism and is relatively rare.
- The condition accounts for about 1-2% of hyperthyroidism-related hospital admissions.
- Thyroid storm affects 0.57 to 0.76 out of every 100,000 people annually in the general US population, and 4.8 to 5.6 out of every 100,000 hospitalized patients each year.
- In Japan, the condition affects about 0.2 out of every 100,000 people each year, which is approximately 0.22% of all patients with an excess of thyroid hormone in the body, and 5.4% of hospitalized patients with this excess.
- People typically affected by thyroid storm are between 42 and 43 years old.
- For every male diagnosed with a thyroid storm, there are about three females diagnosed with the same, which aligns with the larger group of patients with an excess of thyroid hormone in their bodies.
Signs and Symptoms of Thyroid Storm
Thyroid storm is an extreme version of a condition known as hyperthyroidism. It often occurs in response to a sudden trigger. Some common symptoms include high fever, heart problems, nervous system issues, and stomach ailments. Key indicators include a high fever (around 104-106 degrees Fahrenheit), being excessively sweaty, and an excessively fast heart rate (over 140 beats per minute). More severe cardiovascular signs can include heart failure leading to fluid build-up in the lungs and body, low blood pressure, irregular heartbeats, and in some cases, cardiac arrest.
Nervous system-related symptoms may entail restlessness, delirium, anxiety, psychosis, or even falling into a coma. Stomach-related symptoms often include nausea, vomiting, diarrhea, stomach pain, intestinal blockages, or severe liver failure. A study in Japan found that those who presented with nervous system symptoms had a higher risk of death.
During a physical exam, a patient with a thyroid storm might have a high body temperature, a fast heart rate, eye abnormalities, an enlarged thyroid gland, shaky hands, sweaty and warm skin, overactive reflexes, high systolic blood pressure (the top number in a blood pressure reading), and yellow-tinted skin (jaundice).
- High fever (around 104-106 degrees Fahrenheit)
- Excessive sweating
- Fast heart rate (over 140 beats per minute)
- Signs of heart failure (fluid build-up in the lungs and body)
- Low blood pressure
- Irregular heartbeats
- Cardiac arrest
- Restlessness
- Delirium
- Anxiety
- Psychosis or coma
- Nausea
- Vomiting
- Diarrhea
- Stomach pain
- Intestinal blockages
- Severe liver failure
- High body temperature
- Eye abnormalities
- Enlarged thyroid gland
- Shaky hands
- Sweaty and warm skin
- Overactive reflexes
- High systolic blood pressure
- Jaundice (yellow-tinted skin)
Testing for Thyroid Storm
If your doctor suspects you may have an extreme form of hyperthyroidism called a thyroid storm, they will use certain signs and symptoms to make the diagnosis. They won’t wait for lab results to start treatment because this condition is a medical emergency. Even moderately high levels of thyroid hormones can cause a thyroid storm.
Your doctor will likely order a set of lab tests. These tests usually show high levels of thyroid hormones (called FT4 and FT3) and a low level of thyroid-stimulating hormone (TSH). Other potential findings might be high calcium levels, high sugar levels (because thyroid hormones can block the release of insulin and increase the breakdown of sugar stored in your body), abnormal liver function tests, and unusually high or low white blood cell counts.
Doctors often use two scoring systems, the Burch-Wartofsky Point Scale and the Japanese Thyroid Association scoring system, to help them diagnose a thyroid storm. These scales assign points to symptoms like fever, mental confusion, irregular heart rate, heart failure, stomach issues, and the presence of a triggering factor.
According to the Burch-Wartofsky scale, a score over 45 strongly suggests a thyroid storm, a score of 25 to 44 supports the diagnosis, and a score under 25 makes the diagnosis unlikely.
The Japanese Thyroid Association scoring system requires high levels of FT3 and/or FT4 plus various combinations of symptoms. Those include restlessness, fever, fast heartbeat, heart failure, and digestive or liver issues. For definite diagnosis of thyroid storm (TS1), it requires at least one symptom from each category or a combination of at least three out of four categories. A suspected thyroid storm (TS2) requires a combination of at least two of these symptoms.
Keep in mind that these scoring systems are just guides. The diagnosis is made using both the results of these systems and your doctor’s professional judgment. Depending on how you score on these systems, further tests like a chest x-ray, a head CT scan, or an ECG might be needed to check for complications of this condition.
Treatment Options for Thyroid Storm
Treating thyroid storm, an extreme form of hyperthyroidism, involves a variety of supportive measures such as IV fluids, oxygen, cooling blankets, and pain relievers like acetaminophen. If there are identifiable triggers, such as infection, these need to be addressed as part of the treatment plan. Patients experiencing a thyroid storm will typically be admitted to the ICU for intensive care, including close monitoring of heart function and assistance with breathing if necessary.
The medical team will take several steps to treat the condition:
1. They will prescribe medication to control increased adrenaline response in the body.
2. They will use medication to reduce thyroid hormone production.
3. They will administer a kind of iodine solution to lessen the release of thyroid hormone.
4. Certain medications can be used to prevent the conversion of T4, a kind of thyroid hormone, into the more active T3.
5. A type of drug that decreases the re-absorption of thyroid hormones in the gut can be used.
Once the initial supportive measures are implemented, a beta-blocker, a medication that lowers blood pressure and reduces strain on the heart, is usually employed, followed by other specific medications.
Special iodine drops may be provided an hour after taking the first set of medication. Hydrocortisone or similar medication will also be started, which can help reduce inflammation in the body. If a patient’s case is severe, cholestyramine may be prescribed, which helps remove excessive hormones in the body. Lastly, treatment will aim to resolve any precipitating factors. Aspirin, however, should be avoided due to its potential to increase thyroid hormone levels.
During the first day of treatment, thyroid hormone levels come down markedly. After stabilizing initially, the treatment usually transits to a less hepatotoxic medication, which means it is gentler on the liver. There are suitable alternatives available for individuals who cannot consume oral medication, such as enemas or compounds prepared by the pharmacist.
In rare cases, if medications cause an allergic reaction or prove ineffective, alternatives like surgery or plasmapheresis, a procedure that filters blood, may be tried. Once the patient’s condition improves, treatment is adjusted — tapering down glucocorticoids, ceasing the iodine solution, and adjusting the beta-blocker dosage. The patient may then be recommended for definitive treatments like radioiodine therapy or surgical removal of the thyroid gland. Before surgery, patients are put on a course of medication for beta-blockers, glucocorticoids, and iodine. If thyroid storm does not respond to common treatments, plasma exchange could be helpful.
What else can Thyroid Storm be?
A thyroid storm, a severe and life-threatening condition, can sometimes be confused with other illnesses that have similar symptoms. Fever, a common symptom, might lead to a misdiagnosis. Therefore, it’s critical to distinguish thyroid storm from the following conditions:
- Sepsis, a severe infection in the body
- General infections
- Psychosis, a mental health disorder characterized by a disconnection from reality
- Cocaine use
- Pheochromocytoma, a rare tumor of the adrenal glands
- Neuroleptic malignant syndrome, an intense reaction to antipsychotic drugs
- Hyperthermia, a condition where the body’s temperature is significantly above normal
Surgical Treatment of Thyroid Storm
In simpler terms, if your thyroid problem is caused by a condition called toxic adenoma or another called multinodular goiter, the main treatments are usually surgery (resection) or a procedure called radioactive iodine ablation. This procedure uses radioactive iodine to shrink the thyroid. If your thyroid problem is causing discomfort or other symptoms, surgery, also known as a thyroidectomy, is usually preferred. This involves removing some or all of your thyroid.
For those who can’t have or don’t want surgery or ablation, long-term medication that limits thyroid activity could be an option. For a condition like Grave’s disease, which sometimes comes with a mass in the chest that causes severe discomfort, a thyroidectomy is usually the preferred treatment.
However, like any surgery, a thyroidectomy does have risks. It can potentially damage the recurrent laryngeal nerve, which helps control your vocal cords, and lead to hypoparathyroidism, a condition where the parathyroid glands in your neck produce too little parathyroid hormone. This hormone plays a role in regulating the amount of calcium in your body.
What to expect with Thyroid Storm
A thyroid storm is a very serious medical emergency that can be deadly if not treated promptly. It can lead to severe problems such as heart failure, heart rhythm disorders, or failure of multiple organs in the body. But don’t worry – if the condition is treated, most patients start to feel better within 24 hours.
There are several factors that can make the situation worse, such as old age, neurological issues at the time of hospital admission, not using specific medications like beta-blockers and antithyroid drugs, and the need for dialysis or mechanical ventilation. Dialysis is treatment to filter wastes and water from your blood because your kidneys can not do that anymore and mechanical ventilation is a treatment to help a person breathe when they find it difficult or are unable to breathe on their own.
Possible Complications When Diagnosed with Thyroid Storm
If thyroid storm is not treated, it can cause several complications:
- Abnormal heart rhythms (arrhythmias)
- Cardiac failure, where the heart is unable to pump blood efficiently
- Conditions affecting the brain, such as seizures, delirium, or coma
- Raised liver enzymes, indicating liver damage, and yellowing of the skin and eyes (jaundice)
- Abdominal discomfort, vomiting, and diarrhea
- A fast and irregular heartbeat originating in the upper chambers of the heart (atrial fibrillation) and blood clots (thromboembolism)
Preventing Thyroid Storm
Patients who have hyperthyroidism – an overactive thyroid – should be aware of the symptoms of something called a ‘thyroid storm’. This is a serious, but luckily rare, condition that can occur. While it can be dangerous, its impact can be significantly reduced if it’s identified and treated early. It’s crucial that patients with hyperthyroidism seek immediate medical help if they experience any symptoms that might suggest a thyroid storm. After experiencing this first crisis, it’s important for patients to follow their doctor’s advice and treatment plan closely, as this will help prevent further complications. They should fully understand the benefits of the treatment and any potential complications that might arise.
