Thyroid storm

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Thyroid storm
Classification and external resources
ICD-10 E05.5
eMedicine article/925147

Thyroid storm or thyrotoxic crisis is a rare but severe and potentially life-threatening complication of hyperthyroidism (overactivity of the thyroid gland). It is characterized by a high fever (often above 40 °C/104 °F), fast and often irregular heart beat, vomiting, diarrhea, and agitation. Heart failure may occur, and myocardial infarction is encountered. Death may occur despite treatment.[1] Most episodes occur either in those with known hyperthyroidism whose treatment has been stopped or become ineffective, or in those with untreated mild hyperthyroidism who have developed an intercurrent illness (such as an infection).[1]

Pathognesis[edit]

The causes of thyroid storm are multifactorial. Elevated iodothyronine concentrations are only one of many components. Rather, the transition from thyrotoxicosis to thyroid storm is ignited by non-thyroidal triggers including, but not limited to fever, sepsis, dehydration, myocardial infarction and psychiatric diseases[2][3].

According to newer theories thyroid storm results from allostatic failure in a situation were thyrotoxicosis hampers the development of non-thyroidal illness syndrome[4], which would help to save energy in situations of high metabolic demand[3]

Diagnosis[edit]

The probability of thyroid storm in the context of thyrotoxicosis can be assessed with the Burch-Wartofsky score, first introduced in 1993.[1][5] A score is derived from various clinical parameters (such as temperature, heart rate and severity of agitation); a score below 25 signals unlikely thyroid storm, 25–45 suggests impending storm, and above 45 is suggestive of thyroid storm.[6]. Alternatively, the Akamizu criteria, derived from a large cohort of patients with thyroid storm in Japan, provides a similar scale to assess the probability of thyroid storm[7].

Management[edit]

Thyroid storm requires prompt treatment and hospitalization. Often, admission to the intensive care unit is needed.[6] Inorganic iodide (ideally potassium iodide and not Lugol's iodine[citation needed]) and antithyroid drugs (propylthiouracil or methimazole) are used to reduce the release of thyroid hormone from the gland, and beta blockers (e.g. propranolol) to reduce the effect of circulating thyroid hormone on end organs.[1][6] Corticosteroids, like dexamethasone, are used to prevent peripheral conversion of T4 to T3. In high fever, temperature control is achieved with paracetamol/acetaminophen, frequent fluid replacement, mechanical ventilation and corticosteroids.[6] Any suspected underlying cause is also addressed.[1]

References[edit]

  1. ^ a b c d e Klubo-Gwiezdzinska, Joanna; Wartofsky, Leonard (March 2012). "Thyroid emergencies". Medical Clinics of North America. 96 (2): 385–403. doi:10.1016/j.mcna.2012.01.015. PMID 22443982. 
  2. ^ Dietrich, JW (September 2012). "Thyreotoxische Krise [Thyroid storm]". Medizinische Klinik, Intensivmedizin und Notfallmedizin. 107 (6): 448–53. doi:10.1007/s00063-012-0113-2. PMID 22878518. 
  3. ^ a b Dietrich, J. (15 June 2016). "Thyreotoxische Krise und Myxödemkoma". Der Nuklearmediziner. 39 (02): 124–131. doi:10.1055/s-0042-105786. 
  4. ^ Chatzitomaris, Apostolos; Hoermann, Rudolf; Midgley, John E.; Hering, Steffen; Urban, Aline; Dietrich, Barbara; Abood, Assjana; Klein, Harald H.; Dietrich, Johannes W. (20 July 2017). "Thyroid Allostasis–Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming". Frontiers in Endocrinology. 8. doi:10.3389/fendo.2017.00163. PMC 5517413Freely accessible. PMID 28775711. 
  5. ^ Burch, HB; Wartofsky, L (June 1993). "Life-threatening thyrotoxicosis. Thyroid storm". Endocrinology and metabolism clinics of North America. 22 (2): 263–77. PMID 8325286. 
  6. ^ a b c d Bahn, RS; Burch, HB; Cooper, DS; Garber, JR; Greenlee, MC; Klein, I; Laurberg, P; McDougall, IR; Montori, VM; Rivkees, SA; Ross, DS; Sosa, JA; Stan, MN; American Thyroid, Association; American Association of Clinical, Endocrinologists (June 2011). "Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists". Thyroid. 21 (6): 593–646. doi:10.1089/thy.2010.0417. PMID 21510801. 
  7. ^ Akamizu, T; Satoh, T; Isozaki, O; Suzuki, A; Wakino, S; Iburi, T; Tsuboi, K; Monden, T; Kouki, T; Otani, H; Teramukai, S; Uehara, R; Nakamura, Y; Nagai, M; Mori, M; Japan Thyroid, Association. (July 2012). "Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys". Thyroid : official journal of the American Thyroid Association. 22 (7): 661–79. doi:10.1089/thy.2011.0334. PMID 22690898.