Norman is a 64-year-old man with a defibrillator in situ who presented
to his cardiologist when the instrument was activated three times over a
48-hour period. Appropriate cardiac studies were performed without apparent
reason for his defibrillator to kick in.
I saw him in the clinic a few days later and felt comfortable, by
history and exam, that he was hyperthyroid. This was confirmed by lab testing
with undetectable TSH and a markedly elevated free T4 reported by the lab as
>7.0 (reference interval 0.4-2.8).
After discussion with his cardiologist, I arranged his admission to the
major hospital where the cardiologist practiced most often. He was seen by an
endocrinologist who felt that radioactive iodine ablation was the treatment of
choice, but did not think Norman should remain hospitalized for the 1 or 2 days
needed before RAI ablation could be performed. In less than 24 hours he was
back in the ER after his defibrillator went off again. Only then was it decided
to treat him as a patient with thyroid storm and delay RAI ablation.
Jeff is a 47-year-old who had known about his hyperthyroidism for
several months but had only taken methimazole for 1 month. He was laid off from
his job and his health insurance was cut off, such that he claimed he could not
afford any medication. His thyroid disease was clinically as florid as
Norman's, although his free T4 was only 4.7. During his months untreated he had
felt quite unwell and had lost, by his estimation, 20 or 30 pounds in weight.
His BMI in the clinic was 16! Clinically there was no doubt about the diagnosis
of hyperthyroidism, complete with marked exophthalmos and mild thyromegaly, but
he was not in acute distress so I referred him straight to the nuclear medicine
department for definitive ablation therapy.
In general, thyroid storm is one of those conditions in which "you know
it when you see it," but that is not always the case. Clinical findings most
indicative of thyroid storm include hyperthermia, agitation or profound
lethargy, tachycardia and gastro-intestinal dysfunction (diarrhea or vomiting).
The few cases in which I have been involved were hospitalized when I was
invited to consult. All were hyperthermic, markedly agitated and had overt
clinical signs of thyrotoxicosis.
Norman had more abnormal lab findings than Jeff, but Jeff had more overt
thyroid disease. I have done some searching to see if I could find more
specific clues to making a diagnosis of thyroid storm. Not much luck. The
conclusion of a recent review was:
"Although a rare scenario, the management of patients with severe
thyrotoxicosis in the absence of a functional gastrointestinal tract represents
a challenging clinical situation. Endocrinologists and critical care physicians
should be apprised of the available treatment modalities which must be
instituted swiftly in order to avoid a catastrophic outcome."
A second article provided more credence that Norman was indeed
"storming" as emphasized by the abstract:
"We present a case of a 69-year-old male who was hospitalized for the
treatment of thyroid storm due to Grave's disease, who presented with
unexpected ventricular fibrillation (VF). The possible etiology was early
repolarization (ER), characterized by J-point elevation in inferior and
posterolateral leads, unmasked by the attenuation of beta-adrenergic effect
with normalization of thyroid hormones and following the administration of a
beta-blocker. Our case focuses attention on the occurrence of VF in a patient
with ER during the treatment of hyperthyroidism, which to our knowledge is the
first such report."
The treatment of thyroid storm includes standard therapies for
hyperthyroidism in larger doses than in uncomplicated cases: beta blocker,
iodine (SSKI) and glucocorticoids. When there is no doubt about the diagnosis,
the patient should be managed in an intensive care unit with adequate IV
hydration, careful monitoring of vital signs and electrolytes.
For more information:
- Alfadhli E. Thyroid. 2011;21:215-220.
- Ueno A. J Interv Card Electrophysiol. 2010; 29:93-96.