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Thyroid Guide


Thyrotoxic storm

Thyrotoxic storm

General Overview
Thyroid storm or thyrotoxic crisis is an uncommon but serious and critical condition that would require urgent treatment. It is caused by the aggravation of thyrotoxicosis (increased thyroid hormone level)/hyperthyroidism (overactive thyroid). The thyroid is a small butterfly-shaped gland that rests in the lower neck. Its main function is to control your body's growth and metabolism. To control metabolism, your thyroid gland produces hormones (thyroxine [T4] and triiodothyronine [T3]). A properly functioning thyroid will produce the right amount of hormones required to keep your body functioning normally. The level of thyroid hormones in the blood is controlled by your pituitary gland.
The worldwide incidence of thyroid storm is around 1% to 2% among patients with overt hyperthyroidism. Advancement of medicine leading to earlier diagnosis and treatment of hyperthyroidism has lead to this condition becoming very rare. Earlier thyroid storm was a common complication following surgery, but recently it occurs more as a complication of hyperthyroidism, especially when the treatment is not completed or if left untreated or when hyperthyroidism is associated with illness/infections.
Introduction
What is thyroid storm?
Thyroid storm is a serious and critical condition that occurs abruptly due to worsening of the symptoms of hyperthyroidism, which could even lead to death. Characteristically, this condition presents with fever above 41°C (105.8°F). Sometimes, thyroid storm could be quite different from the conventional type, without the usual symptoms such as fever or very mild-to-moderate symptoms. This different form of thyroid storm is known as apathetic storm in which you may have symptoms like excessive weakness, emotional apathy (lack of interest, concern, or emotion), and sometimes, even confusion.
Thyroid storm can lead to complication of various organs. It could affect your heart leading to congestive heart failure (inability of the heart to efficiently pump blood through the body), which in turn could lead to edema (buildup of fluid, in organs and tissues of the body). Your liver may be damaged leading to congestive hepatomegaly (enlarged liver), jaundice, and abdominal pain. It can also cause respiratory distress, and if you are suffering from certain conditions like pneumonia (disease of the lung), viral infection, or other infection of the upper respiratory tract, your symptoms may be masked complicating the early diagnosis.
Death could occur due to rapid development of complications like cardiac arrhythmia (abnormal heart rhythms), congestive heart failure, hyperthermia (excessive rise in body temperature), pulmonary edema, and/or other unknown factors. Early diagnosis and prompt and dynamic treatment in an intensive care unit will reduce the chances of death due to this serious and often critical condition.
Signs and Symptoms
How do I know that I have thyroid storm?
The symptoms of thyroid storm are severe and may include:
  • Fever.
  • Tachycardia (increase in heart rate).
  • Tremor (shakes).
  • Nausea and vomiting.
  • Diarrhea.
  • Dehydration.
  • Incre ased sweating.
  • Abdominal pain.
  • Chest pain.
  • Jaundice.
  • Delirium (an altered state of consciousness).
  • Palpitation.
  • Breathlessness.
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  • Weight loss.
  • Congestive heart failure.
  • Edema.
  • Weakness.
  • Dif ficulty in breathing.
During apathetic storm, you may have:
  • Extreme weakness.
  • Restlessness.
  • Emotional apathy.
  • Confusion/disorientation.
Causes
What is the cause for thyroid storm?
The exact cause for the development of thyroid storm is not yet clearly known. Studies have shown that the levels of free thyroid hormones are increased during thyroid storm, in comparison to patients having uncomplicated thyrotoxicosis. This condition also increases your body's sensitivity to catecholamines, the hormones that stimulate the production of thyroid hormone.
Thyroid storm most commonly occurs in those with Grave's disease (a condition in which your body's defense system reacts abnormally by producing antibodies that stimulate the thyroid tissue to make too much of hormones). In patients with hyperthyroidism, certain events, such as infection, surgery, stress, etc can precipitate thyroid storm.
Risk Factors
Find out if you are at risk of developing thyroid storm
Thyroid storm is usually the result of untreated hyperthyroidism. You can be affected by this condition at any age, though your risk increases as you grow older; you are also at a greater risk, if you are a woman (3 to 5 times more common). Other risk factors will include:
  • Infection.
  • Graves' disease
  • Toxic nodular goiter.
  • Stress.
  • Surgery.
  • Trau ma.
  • Myocardial infarction.
  • Pulmonary embolism.
  • Diabetic ketoacidosis or hypoglycemia.
  • Radioiodine therapy.
  • Withdrawal of antithyroid drug therapy.
  • Pregnancy.
  • Delivery of the baby.
  • Radioactive iodine treatment.
  • Drugs, such as pseudoephedrine and salicylates.
Diagnosis and Screening
How is thyroid storm diagnosed?
Your doctor will diagnose thyroid storm based entirely on his clinical judgment, as there are no characteristic findings that would help him to confirm the diagnosis. He will though order the routine tests for diagnosing hyperthyroidism.
Blood tests:
Free thyroxine (T4) test: This test is done to determine, if your thyroid gland is functioning properly. Thyroxine is a hormone produced by the thyroid gland, which is markedly increased in hyperthyroidism. During this test, your blood is collected from a vein, usually from the inside of your elbow or the back of your hand. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal T4 level will range between 4.5 mcg/dL to 11.2 mcg/dL. In thyroid storm, your T4 level will be elevated.
Triiodothyronine (T3) test: Triiodothyronine is another hormone produced by the thyroid gland, and its level is usually high in hyperthyroidism. During this test, your blood is collected from a vein, usually from the inside of your elbow or the back of your hand. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal T3 level will range between 100 ng/dL to 200 ng/dL. In thyroid storm, your T3 level will be elevated.
Thyroid-stimulating hormone (TSH) test: Thyroid-stimulating hormone is a hormone produced by the pituitary gland that regulates the production and release of the hormones T4 and T3 from the thyroid gland. This blood test is useful for measuring your thyroid function. During this test, your blood is collected from a vein, usually from the bend in your elbow or the back of your hand. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal TSH levels will range between 0.4 mIU/L to 4.0 mIU/L. In thyroid storm, your TSH level will be reduced.
Electrolytes: This test is performed to measure the concentration of electrolytes (sodium, potassium, chloride, and bicarbonate) in your blood. Your doctor might also conduct another test called the anion gap test. This will be calculated using the results of an electrolyte test. Anion gap is useful for the diagnosis of certain conditions like starvation, diabetes, and/or the presence of any toxic substance. Your sample of blood for testing will be taken from a vein in your arm. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal electrolyte levels are given below.
  • Serum sodium. Your normal blood sodium level will range between 135 mEq/L to 145 mEq/L.
  • Serum potassium. Your normal blood potassium level will range between 3.7 mEq/L to 5.2 mEq/L.
  • Serum chloride. Your normal blood chloride levels will range between 96 mEq/L to 106 mEq/L.
  • Serum bicarbonate. Your normal blood bicarbonate level will range between 20 mEq/L to 29 mEq/L.
Serum calcium level: This test is performed to measure the concentration of calcium in your blood. You do not require special preparation for this test. Blood sample for this test will be collected from a vein, usually from the inside of your elbow. As some drugs can alter the results, your doctor may advise you to stop them before the test. Normal serum calcium level ranges from 8.5 mg/dL to 10.2 mg/dL. Your calcium level may be elevated in thyroid storm.
Blood urea nitrogen test: This is a blood test, which is performed to check your kidney functions. The blood sample for the test will be collected from a vein in your arm. As some drugs can alter the results, your doctor may advise you to stop them before the test. The normal value ranges between 7 mg/dL to 20 mg/dL.
Blood sugar (random blood glucose): This test will help to measure your blood glucose levels. Your blood sugar level may be elevated in thyroid storm. Your sample of blood for testing will be taken from a vein in your arm. This test measures the blood glucose (sugar) level and can be done at anytime of day regardless of when you had your last meal or drink. The normal values range between 70 mg/dL to 125 mg/dL (less than 7.0 mmol/L).
Liver function tests: These are a group of blood tests that measures and monitors your liver function. The blood level of your liver enzymes may be elevated in thyroid storm. This test includes the measurement of the following.
  • Alanine aminotransferase (ALT). This is an enzyme found in the liver. The normal range of ALT level is between 5 IU/L to 60 IU/L.
  • Alkaline phosphatase (ALP). This is an enzyme associated with the bile ducts and is usually increased, when they are blocked. The normal range of ALP is from 30 IU/L to 115 IU/L. Alkaline phosphatase level may be increased in thyroid storm.
  • Aspartate aminotransferase (AST). This is an enzyme found in the liver, heart, and other muscles of your body. The normal range for AST level in the bloodstream is 5 IU/L to 43 IU/L.
  • Bilirubin. This is an orange-colored substance in bile (digestive juice secreted by the liver) produced by the breakdown of red blood cells. Generally, both the total bilirubin (the bilirubin in the blood) and direct bilirubin (the form that is combined with another compound in the liver) are measured. Total bilirubin testing measures the amount of bilirubin in the bloodstream. Normal total bilirubin level range from 0.20 mg/dL to 1.50 mg/dL, while the normal level of direct bilirubin range from 0.00 mg/dL to 0.03 mg/dL.
  • Albumin. This is the protein made in the liver. The normal albumin range is from 3.9 g/dL to 5.0 g/dL.
  • Total protein. This test measures albumin and all other proteins present in blood, including antibodies that help to fight off infections. Normal protein levels in the bloodstream range from 6.5 g/dL to 8.2 g/dL.
  • Gamma-glutamyl transferase (GGT). This is produced in the bile ducts (tubes through which bile flows), and it helps in metabolism. The normal range of GGT is from 5 IU/L to 80 IU/L.
  • Prothrombin. This is a protein made in the liver. It is useful for the clotting of blood. This test is performed to calculate the time taken for your blood to clot. The normal time for the blood to clot is between 10 to 15 seconds.
Imaging studies:
Chest X-ray: This is a test, which takes pictures of structures inside the chest to detect abnormalities of the heart, lungs, blood vessels, and chest wall. It is useful to study any changes in your heart like enlargement that could occur with congestive heart failure. It is also helpful to study the presence of fluid in the lungs that could be caused due to heart failure or lung infection associated with thyroid storm.
Computed tomography scan: It is a type of X-ray, which takes detailed pictures of the inside of your body using a computer. This will help your doctor to rule out other conditions that may be causing the symptoms.
Electrocardiogram: This is a simple noninvasive, diagnostic test, which records the electrical activity of the heart. This is the commonest test for diagnosing tachycardia and atrial fibrillation (irregular heart rhythm), and is also useful for detecting any heart damage, which is commonly associated with thyroid storm.
Thyroid ultrasound with Doppler flow: If necessary, your doctor may order this test to assess the size of your thyroid gland, its blood supply, and presence of nodules. This is an imaging test in which high frequency sound waves are used to produce pictures of your thyroid gland. This is a very safe and painless procedure, which can capture real-time images of your thyroid gland. An overactive thyroid is generally enlarged in the ultrasound scan and has increased Doppler flow.
Treatment
If your doctor suspects thyroid storm, he will start immediate treatment in an emergency care setting. Your line of treatment will include the following.
Supportive/nonspecific therapy:
  • Rest.
  • Mild sedation with chlorpromazine, as thyroid storm can cause agitation.
  • Intravenous fluids and electrolyte replacement.
  • Tepid sponging and paracetamol for reducing your fever.
  • Antibiotics.
  • Cardiac support.
  • Oxygen therapy.
  • Nutritional support.
  • Vitamins.
Specific therapy:
  • Beta-blockers. These act by making your heartbeat slower and with less force. This reduces the amount of blood pumped through your blood vessels, decreasing your blood pressure.
  • Antithyroid drugs. These drugs are used to treat the excessive activity of the thyroid gland.
  • Steroids. These drugs help as an adjunctive therapy in reducing the level of T3 hormone.
  • Digoxin. These are drugs, which may make your heart to pump more strongly and can also help to control irregular heartbeats.
  • Diuretics (water pills). These are a group of drugs that are used to reduce the fluid buildup, which occurs in heart failure.
  • Anticoagulants (blood thinners). These are drugs used to reduce blood's clotting ability, thereby preventing thromboembolism (formation of a blood clot in the vessel), heart attack, and stroke.
  • Dialysis. This is an artificial process by which waste products and excess water are removed from your blood. You will undertake dialyses, if your condition does not improve in a day or two, and/or if your doctor suspects infection.
Self Care and Lifestyle Changes
Following a few measures can help to prevent the thyroid crisis. They are mentioned below.
  • Quit smoking, as it could greatly reduce the risk of developing hyperthyroidism and Graves' disease.
  • Avoid foods, such as broccoli, cabbage, sprouts, cauliflower, spinach, soy, beans, mustard greens, refined foods, dairy products, wheat, caffeine, alcohol, caffeinated green tea products, and Chinese or Korean ginseng, as they could interfere with your thyroid function.
  • Avoid stimulants, such as caffeine in coffee, tea, cocoa, chocolate, and drugs like decongestants containing stimulants, as these could worsen your hyperthyroidism.
  • Take good care of your eyes. Consult with your ophthalmologist regularly, and report any symptoms of bulging eyes, as it could be due to increased level of thyroid hormones.
References