Thyroid Storm

Thyrotoxicosis and Thyroid Storm Harrison's Principles of Internal Medicine Perioperative management of the thyrotoxic patient

Bindu Nayak, MD, Kenneth Burman, MD, Endocrinol Metab Clin N Am 35(2006) 663-686

Roy W. Langley, MD, Henry B. Burch, MD, Endocrinol Metab Clin N Am 32 (2003) 519534

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Thyroid Storm

Exacerbation of hyperthyroidism Acute, life-threatening, hypermetabolic state Thyroid storm may be the initial presentation of thyrotoxicosis Less than 10% of hospitalized thyrotoxicosis Mortality: 20-30%

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Thyroid Storm underlying cause

Graves disease Solitary, multinodular goitor Hypersecretory thyroid carcinoma Axis related tumor Hyperthyroidism aggravated by iodine exposure (radiocontrast, Amiodarone)

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Thyroid Storm precipitating event

Systemic insults Discontinuation of antithyroid drug Pseudoephedrine, salicylate use Most common: infection

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Thyroid Storm pathophysiology I

Patients with thyroid storm have relatively higher levels of free thyroid hormones(THs) than patients with uncomplicated thyrotoxicosis, even though total TH levels may not be increased.

Adrenergic receptor activation is a hypothesis. Sympathetic nerves innervate the thyroid gland, and catecholamines stimulate TH synthesis. In turn, increased THs increase the density of betaadrenergic receptors, thereby enhancing the effect of catecholamines.
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Thyroid Storm pathophysiology II

Another theory suggests a rapid rise of hormone levels as the pathogenic source. A drop in binding protein levels, which may occur postoperatively, might cause a sudden rise in free hormone levels. In addition, hormone levels may rise rapidly when the gland is manipulated during surgery, during vigorous palpation during examination, or from damaged follicles following RAI therapy. Other proposed theories include alterations in tissue tolerance to THs, the presence of a unique catecholaminelike substance in thyrotoxicosis, and a direct sympathomimetic effect of TH as a result of its structural similarity to catecholamines.
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Thyroid Storm presentation I

Heat intolerance and diaphoresis are common in simple thyrotoxicosis -> hyperpyrexia in thyroid storm. Extremely high metabolism increases oxygen and energy consumption. Cardiac findings in thyrotoxicosis -> accelerated tachycardia, hypertension, high-output cardiac failure, and a propensity to develop cardiac arrhythmias.

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Thyroid Storm presentation II

irritability and restlessness in thyrotoxicosis -> severe agitation, delirium, seizures, and coma. mild elevations of transaminases and simple enhancement of intestinal transport in thyrotoxicosis -> diarrhea, vomiting, jaundice, and abdominal pain

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Thyroid Storm - diagnosis

37.2 37.7C

40C

A score of 45 or more is highly suggestive of thyroid storm; a score of 25 to 44 supports the diagnosis; and a score below 25 makes thyroid storm unlikely.
Adapted from Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263.

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Thyroid Storm - prognosis

The mortality rate due to cardiac failure, arrhythmia, or hyperthermia is as high as 30%, even with treatment.

Thyrotoxic crisis is usually precipitated by acute illness, surgery (especially on the thyroid), or radioiodine treatment of a patient with partially treated or untreated hyperthyroidism.

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Thyroid Storm treatment I

Medications to halt the synthesis, release, and peripheral effects of thyroid hormone. Controlling adrenergic symptoms and systemic decompensation with supportive therapy

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Thyroid Storm treatment II

Inhibition of new hormone
Thionamide (PTU, MMI)

Removal of excess circulating hormone

Plamapheresis Charcoal plasmaperfusion

Antiadrenergic agents
Reserpine Guanethidine

Inhibition of T4-to-T3 conversion

Inhibition of hormone release

Iodine Potassium iodide, Lugols solution, iopanoic acid Lithium carbonate

PTU Corticosteroids Iopanoic acid, amiodarone Beta-adrenergic blockade Propranolol

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Thyroid Storm treatment III

Thionamides interfere with thyroperoxidasecatalyzed coupling, and inhibitory effect on thyroid follicular cell function and growth Thiouracil (propylthiouracil) v.s. imidazoles (methimazole, carbimazole) SE: abnormal taste, pruritus, urticaria, fever, arthralgia; agranulocytosis, hepatotoxicity, vasculitis

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Thyroid Storm treatment IV

Thionamides interfere with thyroperoxidasecatalyzed coupling, and inhibitory effect on thyroid follicular cell function and growth Thiouracil (propylthiouracil) v.s. imidazoles (methimazole, carbimazole) SE: abnormal taste, pruritus, urticaria, fever, arthralgia; agranulocytosis, hepatotoxicity, vasculitis

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Thyroid Storm treatment V

Large doses of propylthiouracil (600mg loading dose and 200 to 300 mg every 6 h) orally or per rectum; stable iodide is given to block thyroid hormone synthesis via the Wolff-Chaikoff effect : saturated solution of potassium iodide (5 drops SSKI every 6 h), or ipodate or iopanoic acid (0.5 mg every 12 h), may be given orally. (Sodium iodide, 0.25 g intravenously
One hour after the first dose of propylthiouracil, every 6 h is an alternative but is not generally available.)
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Thyroid Storm treatment VI

Propranolol should also be given to reduce tachycardia and other adrenergic manifestations
(40 to 60 mg orally every 4 h; or 2 mg intravenously every 4 h).

Additional therapeutic measures include glucocorticoids (e.g., dexamethasone, 2 mg every 6 h), antibiotics if infection is present, cooling, oxygen, and intravenous fluids.

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Thyroid Storm operation consideration

8%-20% mortality in the past

1% with pre-op inorganic iodine

E.B. Astwood, May 8, 1943: Dr. Plummer Treatment of hyperthyroidism with thiourea and thiouracil. Physician, scientist, architect and engineer, Dr. Henry Plummer has rightly been called "a diversified genius."

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Thyroid Storm operation consideration

Absolute indications
Failed medical therapy Severe reaction to antithyroidal drugs and not a candidate for radioablation therapy Persistent thyrotoxicosis despite maximum antithyroidal drug therapy or repeated radioablation treatments Underlying thyroid cancer Suspicious or malignant nodules on FNA

Relative Indications
Symptomatic goiters Pregnancy Severe Graves ophthalmopathy Refractory thyroiditis Amiodarone related Nonremitting subacute thyroiditis Toxic adenoma Rapid control of symptoms required Aversion to antithyroidal drugs and radioablation therapy
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Thyroid Storm pre-operation consideration

A combination of targets in the thyroid hormone synthetic, secretory and peripheral action pathways. Concurrent treatment to reverse any decompensation of normal homeostatic mechanisms
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Thyroid Storm pre-operation rapid preparation

Beta-adrenergic blockade Thionamide Oral cholecystographic agents Cortiosteroid Continue after operation?

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Thyroid Storm post-operation consideration

Keep regimen after resolution of thyrotoxicity Monitor thyroid hormones To render the patient as close as possible to clinical and biochemical euthyroidism

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Thyroid Storm - Take home message

High fever

A score of 45 or more is highly suggestive of thyroid storm Conscious change

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Thanks you for attention

Rembrandt van Rijn1606 ~ 1669

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