Presentation: 50 yo F patient presents with altered mental status. Her husband reports a history of anxiety, agitation, shortness of breath, vomiting and diarrhea. She has severe tachycardia and hyperthermia. She is delirious and has proptosis and an enlarged thyroid on exam. What’s the diagnosis?
- Thyroid storm is a rare endocrinologic emergency that carries a high mortality if unrecognized. Symptoms are those of extreme hyperthyroidism, including hyperthermia, tachycardia, tremors, heart failure, GI symptoms, and neurologic symptoms. Patients typically have a history of hyperthyroidism (which may be previously undiagnosed) which is exacerbated by a stressor, such as infection, trauma, surgery, MI, or an iodine load (ie iodinated contrast or amiodarone).
- Diagnosis is made by clinical criteria and clinical suspicion. A high level of clinical suspicion should be held in patients with known thyroid disease, those with abnormal thyroids on physical exam, and in cases of unexplained hyperthermia and tachycardia. Scoring criteria have been developed to guide diagnosis:
Recommended treatment has four components:
- 60-80 mg q4hr PO or via NG tube
- 1mg IV q15min
- Preferred beta blocker as it also inhibits T4 –> T3 conversion
- May initiate Esmolol drip if rate control inadequate
- A thionamide
- 500-1000 mg load, then 250 mg q4hr PO or via NG tube
- Also blocks T4 –> T3
- 60-80 mg/day PO or via NG tube
- Less hepatotoxic than PTU
- Saturated Solution of Potassium Iodide (SSKI) 5 drops orally q6hr
- Administer 1 hour after thionamide
- 300 mg IV loading dose, then 100 mg q8hr IV
Teaching point from one of our Endocrine Colleagues:
The only point of controversy is the use of PTU over methimazole. I stopped using PTU and only use methimazole due to the higher number of patients with severe hepatotoxicity. The potential beneficial effect of blocking peripheral conversion of T4 to T3 is not important in somebody who is sick, using beta-blockers and corticosteroids.
Thanks for the post, Eric. Very useful to have all the drugs/dosages presented here. I’d add that the two cases I’ve seen of thyroid storm have presented with significant cardiomyopathy and new AF, which added a whole other level of complexity to these already very ill patients.