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Toxic nodular goiter with thyrotoxic storm — Clinical Guidelines

Overview

Toxic nodular goiter with thyrotoxic storm is a severe, potentially fatal complication characterized by extreme hyperthyroidism leading to multiorgan dysfunction, including cardiovascular collapse, fever, and systemic inflammation akin to cytokine storm syndrome 1 2 11.

Diagnosis

Clinical Features: Hyperthermia, tachycardia, agitation, altered mental status, nausea, vomiting, diarrhea, weight loss, and signs of multiorgan involvement 2 11.

Laboratory Tests: Elevated free T4 and T3 levels, suppressed TSH, increased white cell count, hypernatremia, hypokalemia, elevated liver enzymes, and metabolic acidosis 9 16.

Grading: Diagnostic criteria include FINAL-CRITERIA1 and FINAL-CRITERIA2 for TS1 and TS2, respectively, based on clinical and laboratory findings 20.

Management

First-Line Treatments:

- Antithyroid Drugs: Methimazole or propylthiouracil to inhibit thyroid hormone synthesis 9 17. - Beta-Blockers: For control of tachycardia and hypertension (e.g., esmolol or propranolol) 1 11. - Thyroid Hormone Suppression: Potassium iodide to inhibit peripheral conversion of T4 to T3 11.

Adjunctive Therapies:

- Glucocorticoids: Steroid pulse therapy (e.g., high-dose methylprednisolone) to reduce inflammation 10 17. - Plasma Exchange: For refractory cases with multiorgan failure and coagulopathy 21 27. - Supportive Care: Intensive care unit management, fluid and electrolyte correction, and organ support (e.g., ECMO for severe cardiovascular failure) 3 11.

Special Populations

Pregnancy: Thyroid storm can complicate pregnancy, necessitating urgent management to prevent maternal and fetal morbidity 12.

Comorbidities: Presence of conditions like diabetes (which can trigger thyroid storm) requires careful management to avoid exacerbations 5.

Key Recommendations

Early Recognition and Prompt Treatment: Initiate aggressive treatment immediately upon suspicion of thyroid storm to improve survival outcomes (Evidence: Strong 2 11).

Multidisciplinary Approach: Utilize a multidisciplinary team including endocrinologists, intensivists, and anesthesiologists for comprehensive care (Evidence: Moderate 3 14).

Incorporate Antithyroid Agents and Beta-Blockers: Use methimazole or propylthiouracil and beta-blockers as first-line pharmacological interventions (Evidence: Strong 9 11).

Consider Steroid Pulse Therapy: Employ high-dose glucocorticoids in cases with significant systemic inflammation or refractory multiorgan failure (Evidence: Moderate 10 17).

Evaluate for Plasma Exchange: Consider plasma exchange for patients with refractory multiorgan failure and coagulopathy (Evidence: Weak 21 27).

References

1 Shimizu M. Clinical Features of Cytokine Storm Syndrome. Advances in experimental medicine and biology 2024. link 2 Farooqi S, Raj S, Koyfman A, Long B. High risk and low prevalence diseases: Thyroid storm. The American journal of emergency medicine 2023. link 3 Eltahir M, Chaudhry H, Ibrahim EA, Mokhtar M, Jaouni H, Hassan IF et al.. Thyroid Storm-Induced Refractory Multiorgan Failure Managed by Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case-Series. The American journal of case reports 2023. link 4 Wijeratne S, Chong C, Kirthinanda DS. Anaesthesiology perspective on a multidisciplinary approach to optimal perioperative management of a patient with giant peptic ulcer perforation caused by the physiological stress of a thyroid storm necessitating emergent laparotomy. BMJ case reports 2022. link 5 Iino T, Akatsuka M, Yamamoto S. Case Report: Occurrence of Thyroid Storm in a Young Patient With Recurrent Diabetic Ketoacidosis. Frontiers in endocrinology 2022. link 6 Leviter JI, Sojar S, Ayala NK, Wing R. Thyrotoxicosis in a Postpartum Adolescent: A Simulation Case for Emergency Medicine Providers. MedEdPORTAL : the journal of teaching and learning resources 2020. link 7 Lee JH. Thyroid storm after coronary artery bypass surgery: a case report. Journal of cardiothoracic surgery 2020. link 8 Banerjee A, Bala R, Aggarwal R. Atypical presentation of thyroid storm: a diagnostic dilemma. BMJ case reports 2019. link 9 Tengku Ibrahim TZ, Thambiah SC, Samsudin IN, Nasuruddin AN, Zakaria MH. Thyroid storm: Is there a role for thyroid function test?. The Malaysian journal of pathology 2019. link 10 Andrade Luz I, Pereira T, Catorze N. Thyroid storm: a case of haemodynamic failure promptly reversed by aggressive medical therapy with antithyroid agents and steroid pulse. BMJ case reports 2018. link 11 Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K et al.. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocrine journal 2016. link 12 Kofinas JD, Kruczek A, Sample J, Eglinton GS. Thyroid storm-induced multi-organ failure in the setting of gestational trophoblastic disease. The Journal of emergency medicine 2015. link 13 Moraco AH, Banauch G, Kopec S. A 46-Year-Old Woman With Dyspnea From an Inhalational Exposure, Triggering Thyroid Storm and Subsequent Multi-Organ System Failure. Journal of intensive care medicine 2015. link 14 Uchida N, Suda T, Ishiguro K. Thyroidectomy in a patient with thyroid storm: report of a case. Surgery today 2015. link 15 Finco D, Grimaldi C, Fort M, Walker M, Kiessling A, Wolf B et al.. Cytokine release assays: current practices and future directions. Cytokine 2014. link 16 Shimoda Y, Satoh T, Takahashi H, Katano-Toki A, Ozawa A, Tomaru T et al.. A case of thyroid storm with a markedly elevated level of circulating soluble interleukin-2 receptor complicated by multiple organ failure and disseminated intravascular coagulation syndrome. Endocrine journal 2014. link 17 Kulaksizoglu M, Gonen MS, Kebapcilar L, Sahin F, Acikgoz B, Demir T et al.. Multiorgan dysfunction accompanied with metimazole and thyroid storm. Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis 2012. link 18 Harada Y, Akiyama H, Yoshimoto T, Urao Y, Ryuzaki M, Handa M. Thyroid storm with multiple organ failure, disseminated intravascular coagulation, and stroke with a normal serum FT3 level. Internal medicine (Tokyo, Japan) 2012. link 19 Deng Y, Zheng W, Zhu J. Successful treatment of thyroid crisis accompanied by hypoglycemia, lactic acidosis, and multiple organ failure. The American journal of emergency medicine 2012. link 20 Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T et al.. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid : official journal of the American Thyroid Association 2012. link 21 Sasaki K, Yoshida A, Nakata Y, Mizote I, Sakata Y, Komuro I. A case of thyroid storm with multiple organ failure effectively treated with plasma exchange. Internal medicine (Tokyo, Japan) 2011. link 22 Chong HW, See KC, Phua J. Thyroid storm with multiorgan failure. Thyroid : official journal of the American Thyroid Association 2010. link 23 Sandilands GP, Wilson M, Huser C, Jolly L, Sands WA, McSharry C. Were monocytes responsible for initiating the cytokine storm in the TGN1412 clinical trial tragedy?. Clinical and experimental immunology 2010. link 24 Karanikolas M, Velissaris D, Karamouzos V, Filos KS. Thyroid storm presenting as intra-abdominal sepsis with multi-organ failure requiring intensive care. Anaesthesia and intensive care 2009. link 25 Hsiao FC, Hung YJ, Hsieh CH, Wu LY, Shih KC, He CT. Abdominal pain and multi-organ dysfunction syndrome in a young woman. The American journal of the medical sciences 2007. link 26 Charles RA, Goh SY. Not just gastroenteritis: thyroid storm unmasked. Emergency medicine Australasia : EMA 2004. link 27 Kokuho T, Kuji T, Yasuda G, Umemura S. Thyroid storm-induced multiple organ failure relieved quickly by plasma exchange therapy. Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy 2004. link 28 Jiang YZ, Hutchinson KA, Bartelloni P, Manthous CA. Thyroid storm presenting as multiple organ dysfunction syndrome. Chest 2000. link 29 Pugh S, Lalwani K, Awal A. Thyroid storm as a cause of loss of consciousness following anaesthesia for emergency caesarean section. Anaesthesia 1994. link 30 Murray JF. Hyperpyrexia of uncertain origin. British journal of anaesthesia 1978. link

Toxic nodular goiter with thyrotoxic storm