Thyroid storm

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🔢 No.	Thyroid Crisis🩺 Key Point
1	Thyroid storm is a life-threatening exacerbation of thyrotoxicosis.
2	Common triggers: infection, surgery, trauma, childbirth, and RAI therapy.
3	Classic features: hyperpyrexia, tachycardia, CNS dysfunction, GI symptoms.
4	CNS signs may include agitation, delirium, or coma.
5	Burch-Wartofsky Score helps diagnose thyroid storm (score >45 = likely).
6	TSH is suppressed; free T3 and T4 are elevated.
7	Atrial fibrillation is a common ECG finding.
8	GI symptoms include nausea, vomiting, and diarrhea.
9	PTU is preferred over methimazole in thyroid storm.
10	PTU inhibits thyroid hormone synthesis and peripheral conversion (T4→T3).
11	Propranolol reduces adrenergic symptoms and T4→T3 conversion.
12	Iodine (e.g., Lugol’s) should be given 1 hr after thionamide.
13	Hydrocortisone is used to treat relative adrenal insufficiency.
14	Supportive care (ICU, fluids, cooling) is the first step in management.
15	Cholestyramine may lower hormone levels by interrupting enterohepatic cycle.
16	Liver dysfunction with elevated transaminases may occur.
17	Hypercalcemia and hyperglycemia can be seen.
18	Most cases are due to underlying Graves’ disease.
19	Mortality exceeds 30% without prompt treatment.
20	Beta-blockers and steroids are essential alongside antithyroid drugs.

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Thyroid crisis

Also known as thyrotoxic crisis – It is a rare and life-threatening complication of hyperthyroidism. It happens when the thyroid gland releases a large amount of thyroid hormone in a short amount of time, causing the body’s metabolism to go into overdrive, which can be extremely dangerous. 

Causes and triggers

Usually triggered by a sudden and intense event in individuals with diagnosed or undiagnosed hyperthyroidism. Common triggers include: 

• Stopping antithyroid medications suddenly.
• Surgery (thyroid or non-thyroidal).
• Trauma or infection.
• Acute illnesses like diabetic ketoacidosis, heart failure, or drug reactions.
• Exposure to large amounts of iodine (e.g., from certain imaging procedures).
• Giving birth.
• Stroke. 

Symptoms

Symptoms are a severe exaggeration of hyperthyroidism symptoms, and can include:

• High fever (often 104-106°F or higher).
• Rapid heart rate (tachycardia) that may exceed 140 beats per minute.
• Agitation, irritability, and anxiety.
• Delirium or psychosis.
• Heart failure.
• Loss of consciousness.
• Less common symptoms include severe nausea, vomiting, diarrhea, abdominal pain, and jaundice. 

Diagnosis and treatment

Diagnosis of is primarily based on clinical symptoms rather than laboratory findings, as waiting for test results can delay life-saving treatment. Treatment involves: 

• Supportive measures such as oxygen, IV fluids, cooling blankets, and fever reducers.
• Antithyroid medications like propylthiouracil (PTU) or methimazole to block hormone synthesis.
• Iodine preparations (given at least an hour after antithyroid medication) to block hormone release.
• Beta-blockers to manage cardiovascular symptoms.
• Glucocorticoids to reduce peripheral T4 to T3 conversion and address potential adrenal insufficiency.
• Bile acid sequestrants to prevent reabsorption of free thyroid hormones in the gut.
• Treating the underlying cause that triggered the storm.
• Plasmapheresis may be considered in rare, resistant cases. 

This is a medical emergency requiring immediate attention and hospitalization, often in an intensive care unit (ICU). 

Prognosis

This is fatal if left untreated. Even with treatment, the mortality rate is estimated to be between 8% and 25%. With prompt and adequate treatment, clinical improvement is often seen within 24 hours. The crisis typically resolves within a week. Risk factors for a poor prognosis include advanced age, central nervous system (CNS) dysfunction, failure to use beta-blockers and antithyroid medications, and the need for dialysis or mechanical ventilation. 

If you suspect – seek immediate medical attention by calling emergency services or going to the nearest hospital. 

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Thyroid crisis

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