Thyroid storm is an urgent complication of diffuse toxic goiter, provoked by an increase in the activity of thyroid hormones in the blood. It is manifested by fever, sweating, palpitations, shortness of breath, hypertension, abdominal pain, nausea and vomiting, diarrhea, anxiety and excitement. In severe cases, coma develops, and then death. The diagnosis is established based on the results of a survey, examination, laboratory tests and an ECG. Treatment is mainly medical, aimed at eliminating thyrotoxicosis and restoring vital functions.
E05.5 Thyroid storm or coma
According to the majority of researchers in the field of practical endocrinology, a thyroid storm develops only with basal disease, some sources indicate the possibility of this complication against the background of intoxication with Plummer’s disease. According to various statistics, the frequency of the crisis state is from 0.5 to 9% of cases of severe thyrotoxicosis. The gender ratio is the same as in diffuse toxic goiter: in the female population, epidemiological indicators are 9 times higher than in the male. The average duration of thyrotoxicosis, which precedes the crisis, is 2-4 years, the developed symptoms of hyperthyroidism are observed for at least 2 years.
The most common etiofactor of the development of a crisis is thyroid surgery for thyrotoxic adenoma or diffuse thyrotoxic goiter. To reduce the risk of complications, proper preparation of patients for surgery is necessary – achieving stable euthyroidism with the help of drug therapy. Less frequent causes of the crisis include:
- Operations on other organs. Surgical procedures can provoke an increase in the production of iodized hormones. The risk increases with the use of ether anesthesia.
- Infectious diseases. The acute course of infections in people with Graves’ disease increases the likelihood of a crisis. The most dangerous in this regard are bronchopulmonary diseases.
- Diabetes mellitus. The provoking factors are the metabolic complications of diabetes mellitus. Thyroid hormones are produced more actively in ketoacidosis, hyperosmolar coma and hypoglycemia due to the administration of large doses of insulin.
- Provocation of thyrotoxicosis. Exacerbation of thyrotoxicosis may be caused by external factors that stimulate the secretion of iodine-containing hormones. These include self-cancellation or change in the dosage of antithyroid drugs, radioiodine therapy, X-ray examinations using iodine contrasts, treatment with potassium iodide solution, traumatic palpation of goiter.
- Severe concomitant diseases. The development of a crisis can be associated with a violation of cerebral circulation, pulmonary embolism, acute gastroenteritis, injuries. Pregnant women and women in labor are at increased risk.
Pathogenetic mechanisms remain not fully understood. There is a widespread theory about the development of complications due to excessive secretion of thyroxine and triiodothyronine. According to studies, the activity of the thyroid gland in patients is indeed increased, but no more than in the normal course of thyrotoxicosis without complications. The assumption about the leading role of free (unrelated) hormones T3 and T4 was also not confirmed.
Another theory that continues to be developed is based on the hypothesis of catecholamine hyperactivity as a key factor in the manifestation of a crisis. The concentration of adrenaline and norepinephrine in plasma does not increase, but there are two separate systems in the heart muscle that are sensitive to catecholamines and thyroid hormones, and the combined effect of these compounds is manifested by a crisis.
Proponents of the third theory consider the strengthening of the peripheral reaction to the influence of triiodothyronine and thyroxine as the pathogenetic basis of thyroid storm. As a result, lipolysis and heat production increase, the temperature rises, the resistance of tissues to the effects of thyroid hormones is depleted, decompensation of Graves’ disease develops.
Thyroid storm symptoms
Most often, there is a sudden and rapid increase in clinical signs, in rare cases, patients manage to recognize the prodromal period as a barely noticeable increase in the symptoms of thyrotoxicosis. The manifestation of the crisis is manifested by the development of fever, sweating, tachycardia, psychomotor agitation. The temperature rises to 38-41 ° C, the pulse rate increases to 120-200 beats /min. Sweat is released in a large volume, quickly provokes dehydration. Patients begin to experience panic, fear of loss of consciousness, death.
In 90% of cases, there is a disorder of the functions of the central nervous system. At the first stage, symptoms of motor and mental arousal prevail: patients are anxious, emotionally unstable (crying, showing aggression, laughing), hyperactive and purposeless in behavior. Psychosis may develop. As the crisis progresses, this state is replaced by lethargy, apathy, emotional stupor, extreme muscle weakness. The thyrotoxic form of myopathy is manifested by a decrease in tone and rapid fatigue of the muscles of the neck, scapula, arms and legs, less often – the face and trunk. There may be pain, involuntary twitching, convulsions, hypokalemic paroxysmal paralysis (paroxysmal pronounced muscle weakness).
Symptoms of gastrointestinal disorders include nausea, vomiting, decreased appetite, spastic abdominal pain, frequent defecation, diarrhea and, as a result, weight loss. The work of the kidneys is disrupted, the volume of urine excreted is reduced until its complete absence (anuria). Half of the patients develop cardiovascular disorders: tachycardia, arrhythmias. The heart rate increases, blood pressure increases, shortness of breath appears, breathing becomes difficult.
People over 60 years of age are more likely to develop an atypical form of thyroid storm. It is characterized by a latent course or the dominance of symptoms of pathology of any one system of the body, which significantly complicates diagnosis. With the latent version of the crisis, patients are in a lethargic state, inhibited, apathetic. The omission of the upper eyelid (blepharoptosis), myopathy may be determined. In the “masked” variant, isolated symptoms of disorders of the nervous, cardiovascular, respiratory or digestive system unfold.
The lack of emergency treatment for thyroid storm leads to severe complications. In the terminal stage, there is a complete heart block, congestive heart failure, vascular collapse. The risk of reflex pulmonary edema and hepatomegaly with necrosis of liver tissues increases. The condition of patients progressively worsens over 48-72 hours, confusion and apathy are replaced by coma. Death occurs as a result of insufficiency of heart functions, the development of hypovolemic shock – a rapid decrease in the volume of circulating blood and dehydration.
The examination is performed by an endocrinologist. Diagnostics is performed on an emergency basis, includes a set of procedures to assess the anamnesis and severity of the patient’s current condition, to identify signs confirming decompensation of thyrotoxicosis. With a detailed clinical picture, differential diagnosis is not relevant, with uneven manifestation of symptoms, it may be necessary to exclude heart failure, acute intoxication. The comprehensive study includes:
- Clinical survey. All patients have a history of a diagnosis of “diffuse toxic goiter”, most have a provoking factor in the recent past – surgery, radioiodine treatment, taking iodine-containing drugs, etc. Patients report a feeling of weakness, lethargy, shortness of breath, trembling, sweating, disorders of the digestive tract.
- Inspection. There is a fever, a state of nervous excitement. When palpating the abdomen, soreness is noted. Blood pressure measurement gives elevated and high values – from 130 to 300 mm Hg. Phonendoscopic examination reveals tachycardia. Body temperature – from 38° to 41 °C.
- Laboratory tests. Studies of hormones and blood glucose levels are being conducted. The crisis is characterized by an increase in the content of thyroxine (T4), triiodothyronine (T3); a decrease in the concentration of thyrotropin (TSH) and cortisol. Hyperglycemia, low cholesterol levels are often detected.
- ECG. According to electrocardiographic examination, sinus tachycardia and atrial fibrillation, an increase in the amplitude of the T and QRS waves are diagnosed. Sometimes impaired intraventricular conduction is determined.
Thyroid storm treatment
Therapy includes general measures to restore the vital functions of the body, as well as the elimination of the state of decompensation of the disease. Emergency care is carried out at the prehospital stage and is aimed at restoring the water-electrolyte balance, maintaining respiratory function and heart function. After confirmation of the diagnosis, an individual treatment regimen is developed, which includes the following components:
- Antithyroid therapy. Procedures are carried out that reduce the level of triiodothyronine and thyroxine to normal. Patients are prescribed thyrostatics, iodides, beta-blockers. If drug treatment is ineffective, plasmapheresis or hemosorption is used to remove T3 and T4 from the blood.
- Restoration of body functions. Infusion therapy with glucose solution and sodium chloride solution is indicated for all patients. These procedures eliminate dehydration, normalize the level of electrolytes. Arterial hypertension is stopped by hypotensive agents, hypotension – vasopressor drugs, cardiovascular insufficiency – cardiac glycosides. Patients in serious condition may need oxygen therapy procedures, artificial ventilation of the lungs.
Elimination of concomitant diseases. In parallel, the treatment of pathological conditions that provoke and support a crisis is carried out. Antibiotics are used for bacterial infections, and insulin preparations are used for decompensation of diabetes mellitus. Prescriptions of medications that can enhance the production of thyroid hormones are being reviewed.
Prognosis and prevention
With proper treatment, the acute condition can be eliminated within 3-5 days. In a stable period, constant monitoring of hormone levels is required. The key point in the prevention of thyroid storm is the proper preparation of patients for surgery and treatment with radioactive iodine: with the help of drug therapy, a relatively stable state of euthyroidism should be achieved – the normal concentration of thyroid hormones in the blood. In addition, all patients need regular monitoring by a doctor, unscheduled consultations and examinations during the development of an infectious disease, after injuries, before operations and childbirth, during pregnancy.