Thyroid storm: An early clinical diagnosis and multidrug approach to therapy
K Chatterjee1, C Sen2, GC Ghosh1,
1 Department of Medicine, Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Medicine, Medical College, Kolkata, West Bengal, India
Department of Medicine, Dr. Ram Manohar Lohia Hospital, New Delhi
|How to cite this article:|
Chatterjee K, Sen C, Ghosh G C. Thyroid storm: An early clinical diagnosis and multidrug approach to therapy.J Postgrad Med 2013;59:339-340
|How to cite this URL:|
Chatterjee K, Sen C, Ghosh G C. Thyroid storm: An early clinical diagnosis and multidrug approach to therapy. J Postgrad Med [serial online] 2013 [cited 2020 Jun 5 ];59:339-340
Available from: http://www.jpgmonline.com/text.asp?2013/59/4/339/123187
We read with interest the case of thyroid storm presenting as congestive heart failure with thrombosis reported by Kumar et al.  We were pleased to note that the patient improved with the prompt treatment instituted. However, we would like to offer our views regarding some aspects of the diagnosis and management of a case of thyroid storm not touched upon in the article.
Though the differentiation between severe thyrotoxicosis and thyroid storm is controversial and remains subjective, Burch and Wartofsky delineated a scoring system based on dysfunction of various systems (thermoregulatory, central nervous, gastrointestinal, and cardiovascular) and presence of precipitating factors.  According to this scoring system a score of 45 and above is highly suggestive of thyroid storm, a score of 25-44 is suggestive of impending storm, and a score below 25 is unlikely to represent thyroid storm. The patient in question had bibasilar rales and a heart rate of 126 bpm getting 10 and 15 points respectively. The patient also had mild derangement of liver functions and was febrile but did not have a recognisable precipitating factor. No mention is made of her neurological status in the report. Taking all this into account it can be safely assumed that the patient probably had a score highly suggestive of thyroid storm or impending storm. This clinical scoring system can be useful in patients with high output cardiac failure suspected to have thyroid storm when obvious signs of thyrotoxicosis like ophthalmopathy, goitre and pretibial myxedema are absent.
It is important to note that the pattern of raised free T 4 and free T 3 and suppressed TSH is similar in both thyrotoxicosis and thyroid storm and there is no cut-off value beyond which the results can be attributed to thyroid storm.  Radiologic imaging is not necessary for diagnosis of thyroid storm though ultrasound of the thyroid with Doppler is a useful bedside test in such patients to assess thyroid size, vascularity and presence of nodules.  Radioiodine thyroid scans do not add any extra information in this emergency situation and are best avoided till the crisis is over.
A multidrug approach must be strongly advocated in the emergent management of life-threatening thyroid storm. Therapy should be started with propylthiouracil or carbimazole followed by iodine therapy in the form of oral Lugol's iodine or saturated solution of potassium iodide after 30-60 mins of starting thionamides. Beta blockers play an important role in restricting the peripheral action of steroid hormones. In patients with heart failure it is prudent to choose a short acting drug like esmolol with close hemodynamic monitoring.  Thyroid storm is a state of functional adrenal insufficiency due to increased cortisol metabolism. Glucocorticoids also inhibit peripheral conversion of T 4 to T 3 . Thus, their use has become standard practise in patients with thyroid storm and hypotension. 
To conclude, we would like to stress that reaching an early clinical diagnosis and starting aggressive multidrug therapy are essential to ensure good outcome in cases of thyroid storm.
|1||Kumar S, Moorthy N, Yadav S, Kapoor A, Dale DC. Thyroid storm presenting as congestive heart failure and protein-S deficiency-induced biventricular and internal jugular venous thrombii. J Postgrad Med 2013;59:229-31.|
|2||Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77.|
|3||Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin N Am 2006;35:663-86.|
|4||Klein I, Ojamaa K. Thyrotoxicosis and the heart. Endocrinol Metab Clin North Am 1998;27:51-62.|
|5||Dluhy RG. The adrenal cortex in thyrotoxicosis. In: Braverman LE, Utiger RD, editors. Werner's and Ingbar's The thyroid. 9 th ed. Philadelphia: Lipincott, Williams & Wilkins; 2005. p. 602-3.|