Hyperthyroidism, Thyroid Storm, and Graves Disease
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Hyperthyroidism, thyroid storm, and Graves disease are conditions of excess thyroid hormone. The elevated level of thyroid hormones can result in clinical manifestations ranging from mild to severely toxic with resultant morbidity and mortality for affected patients.
Hyperthyroidism presents as a constellation of symptoms due to elevated levels of circulating thyroid hormones. Because of the many actions of thyroid hormone on various organ systems in the body, the spectrum of clinical signs produced by the condition is broad. The presenting symptoms can be subtle and nonspecific, making hyperthyroidism difficult to diagnose in its early stages without the aid of laboratory data.
The term hyperthyroidism refers to inappropriately elevated thyroid function. Though often used interchangeably, the term thyrotoxicosis, which refers to an excessive amount of circulating thyroid hormone, is not synonymous with hyperthyroidism. Increased levels of hormone can occur despite otherwise normal thyroid function, such as in instances of inappropriate exogenous thyroid hormone or excessive release of stored hormone from an inflamed thyroid gland.
Graves disease (diffuse toxic goiter), the most common form of overt hyperthyroidism, is an autoimmune condition in which autoantibodies are directed against the thyroid-stimulating hormone (TSH) receptor. As a result, the thyroid gland is inappropriately stimulated with ensuing gland enlargement and increase of thyroid hormone production. Risk factors for Graves disease include family history of hyperthyroidism or various other autoimmune disorders, high iodine intake, stress, use of sex steroids, and smoking. The disease is classically characterized by the triad of goiter, exophthalmos, and pretibial myxedema.
Thyroid storm is a rare and potentially fatal complication of hyperthyroidism. [1] It typically occurs in patients with untreated or partially treated thyrotoxicosis who experience a precipitating event such as surgery, infection, or trauma. Thyroid storm must be recognized and treated on clinical grounds alone, as laboratory confirmation often cannot be obtained in a timely manner. Patients typically appear markedly hypermetabolic with high fevers, tachycardia, nausea and vomiting, tremulousness, agitation, and psychosis. Late in the progression of disease, patients may become stuporous or comatose with hypotension.
For more information, see Medscape’s Thyroid Disease Resource Center.
In healthy patients, the hypothalamus produces thyrotropin-releasing hormone (TRH), which stimulates the anterior pituitary gland to secrete thyroid-stimulating hormone (TSH); this in turn triggers the thyroid gland to synthesize thyroid hormone.
Thyroid hormone concentration is regulated by negative feedback by circulating free hormone primarily on the anterior pituitary gland and to a lesser extent on the hypothalamus. The secretion of TRH is also partially regulated by higher cortical centers.
The thyroid gland produces the prohormone thyroxine (T4), which is deiodinated primarily by the liver and kidneys to its active form, triiodothyronine (T3). The thyroid gland also produces a small amount of T3 directly. T4 and T3 exist in 2 forms: a free, unbound portion that is biologically active and a portion that is protein bound to thyroid-binding globulin (TBG). Despite consisting of less than 0.5% of total circulating hormone, free or unbound T4 and T3 levels best correlate with the patient’s clinical status.
The overall incidence of hyperthyroidism is estimated between 0.05% and 1.3%, with the majority consisting of subclinical disease. A population-based study in the United Kingdom and Ireland found an incidence of 0.9 cases per 100,000 children younger than 15 years, showing that the disease incidence increases with age. [2] The prevalence of hyperthyroidism is approximately 5-10 times less than hypothyroidism.
Thyroid storm is a rare disorder. Approximately 1-2% of patients with hyperthyroidism progress to thyroid storm. In Japan, the estimated incidence of thyroid storm in hospitalized patients is 0.20 per 100,000 annually, according to a study by Akamizu, with the rate being 0.22% of all thyrotoxic patients. [3]
Thyroid storm, if unrecognized and untreated, is often fatal. Adult mortality rate from thyroid storm is approximately 10-20%, but it has been reported to be as high as 75% in hospitalized populations. Underlying precipitating illness may contribute to high mortality.
A study by Ono et al of 1324 patients indicated that the following factors are associated with increased mortality risk in thyroid storm [4] :
In addition, a study by Swee et al of 28 patients with thyroid storm reported that CNS dysfunction of greater than mild severity appeared to be a risk factor for mortality. [5]
A study by Mohananey et al found that among patients hospitalized in the United States with thyroid storm, the incidence of cardiogenic shock increased from 0.5% in 2003 to 3% in 2011. However, the mortality rate among the cardiogenic shock patients fell from 60.5% in 2003 to 20.9% in 2011. The investigators also reported that a history of atrial fibrillation, alcohol abuse, preexisting congestive heart failure, coagulopathy, drug use, liver disease, pulmonary circulatory disease, valvular disease, weight loss, renal failure, and fluid and electrolyte disease was more likely in thyroid storm patients with cardiogenic shock than in other thyroid storm patients. [6]
See the list below:
White and Hispanic populations in the United States have a slightly higher prevalence of hyperthyroidism in comparison with black populations.
See the list below:
A slight predominance of hyperthyroidism exists among females.
See the list below:
Thyroid storm may occur at any age but is most common in those in their third through sixth decades of life.
Graves disease predominantly affects those aged 20-40 years.
The prevalence of toxic multinodular goiter increases with age and becomes the primary cause of hyperthyroidism in elderly persons.
Pokhrel B, Bhusal K. Thyroid, Storm. 2018 Jan. [Medline]. [Full Text].
Williamson S, Greene SA. Incidence of thyrotoxicosis in childhood: a national population based study in the UK and Ireland. Clin Endocrinol (Oxf). 2010 Mar. 72(3):358-63. [Medline].
Akamizu T. Thyroid Storm: A Japanese Perspective. Thyroid. 2018 Jan. 28 (1):32-40. [Medline].
Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan. Medicine (Baltimore). 2016 Feb. 95 (7):e2848. [Medline].
Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract. 2015 Feb. 21 (2):182-9. [Medline].
Mohananey D, Smilowitz N, Villablanca PA, et al. Trends in the Incidence and In-Hospital Outcomes of Cardiogenic Shock Complicating Thyroid Storm. Am J Med Sci. 2017 Aug. 354 (2):159-64. [Medline].
Hamnvik OP, Larsen PR, Marqusee E. Thyroid dysfunction from antineoplastic agents. J Natl Cancer Inst. 2011 Nov 2. 103(21):1572-87. [Medline]. [Full Text].
Nguyen CT, Sasso EB, Barton L, Mestman JH. Graves’ hyperthyroidism in pregnancy: a clinical review. Clin Diabetes Endocrinol. 2018. 4:4. [Medline]. [Full Text].
FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). US Food and Drug Administration. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm164162.htm. Accessed: June 3, 2009.
Kreisner E, Lutzky M, Gross JL. Charcoal hemoperfusion in the treatment of levothyroxine intoxication. Thyroid. Feb 2010. 20(2):209-12. [Medline].
Vyas AA, Vyas P, Fillipon NL, Vijayakrishnan R, Trivedi N. Successful treatment of thyroid storm with plasmapheresis in a patient with methimazole-induced agranulocytosis. Endocr Pract. 2010 Jul-Aug. 16(4):673-6. [Medline].
Alfadhli E, Gianoukakis AG. Management of severe thyrotoxicosis when the gastrointestinal tract is compromised. Thyroid. 2011 Mar. 21(3):215-20. [Medline].
Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011 May-Jun. 17 (3):456-520. [Medline]. [Full Text].
[Guideline] Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016 Oct. 26 (10):1343-421. [Medline]. [Full Text].
[Guideline] Satoh T, Isozaki O, Suzuki A, et al. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J. 2016 Dec 30. 63 (12):1025-64. [Medline]. [Full Text].
[Guideline] Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017 Mar. 27 (3):315-89. [Medline]. [Full Text].
Tun NN, Beckett G, Zammitt NN, Strachan MW, Seckl JR, Gibb FW. Thyrotropin Receptor Antibody Levels at Diagnosis and After Thionamide Course Predict Graves’ Disease Relapse. Thyroid. 2016 Aug. 26 (8):1004-1009. [Medline].
Rabon S, Burton AM, White PC. Graves’ Disease in Children: Long Term Outcomes of Medical Therapy. Clin Endocrinol (Oxf). 2016 May 12. [Medline].
Chong HW, See KC, Phua J. Thyroid storm with multiorgan failure. Thyroid. Mar 2010. 20(3):333-6. [Medline].
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.
Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School
Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society
Disclosure: Nothing to disclose.
Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine
Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Hyperthyroidism, Thyroid Storm, and Graves Disease
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