Stormin' Norman

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.