Thyroid Storm (Thyrotoxic Crisis)

  • Leonard WartofskyEmail author
  • Joanna Klubo-Gwiezdzinska


Thyroid storm or thyrotoxic crisis is the most severe manifestation of hyperthyroidism that can present with or evolve into systemic decompensation with multi-organ failure and death. Aggressive therapy is required, preferably in an intensive care unit in order to avoid a disastrous outcome.


Hyperthyroidism Hyperthermia Tachycardia Heart failure Antithyroid drugs Beta-blockers Ophthalmopathy 


  1. 1.
    Swinburne JL, Kreisman SH. A rare case of subacute thyroiditis causing thyroid storm. Thyroid. 2007;17:73–6.CrossRefGoogle Scholar
  2. 2.
    Yoon SJ, Choi SR, Kim DM, et al. A case of thyroid storm due to thyrotoxicosis factitia. Yonsei Med J. 2003;44:351–4.CrossRefGoogle Scholar
  3. 3.
    Klubo-Gwiezdzinska J, Wartofsky L. Thyrotoxic storm. In: Oxford textbook of endocrinology and diabetes. 2nd ed. Oxford: Oxford University Press; 2011. p. 454–61.Google Scholar
  4. 4.
    Moskovitz JB, Bond MC. Molar pregnancy induced thyroid storm. J Emerg Med. 2010;38:e71–6.CrossRefGoogle Scholar
  5. 5.
    Tewari K, Balderston KD, Carpenter SE, et al. Papillary thyroid carcinoma manifesting as thyroid storm of pregnancy: case report. Am J Obstet Gynecol. 1998;179:818–9.CrossRefGoogle Scholar
  6. 6.
    McDermott MT, Kidd GS, Dodson LE, et al. Radioiodine-induced thyroid storm. Am J Med. 1983;75:353–9.CrossRefGoogle Scholar
  7. 7.
    Naito Y, Sone T, Kataoka K, et al. Thyroid storm due to functioning metastatic thyroid carcinoma in a burn patient. Anesthesiology. 1997;87:433–5.CrossRefGoogle Scholar
  8. 8.
    Al-Anazi KA, Inam S, Jeha MT, et al. Thyrotoxic crisis induced by cytotoxic chemotherapy. Support Care Cancer. 2005;13:196–8.CrossRefGoogle Scholar
  9. 9.
    Sebe A, Satar S, Sari A. Thyroid storm induced by aspirin intoxication and the effect of hemodialysis: a case report. Adv Ther. 2004;21:173–7.CrossRefGoogle Scholar
  10. 10.
    Hirvonen EA, Niskanen LK, Niskanen MM. Thyroid storm prior to induction of anaesthesia. Anaesthesia. 2004;59:1020–2.CrossRefGoogle Scholar
  11. 11.
    Yuan YD, Seak CJ, Lin CC, et al. Thyroid storm precipitated by organophosphate intoxication. Am J Emerg Med. 2007;25:861.CrossRefGoogle Scholar
  12. 12.
    Haraldsdottir A, Li Q, Villalona-Calero MA, Olencki TE, Kendra K. Case of sorafenib-induced thyroid storm. J Clin Oncol. 2013;31:e262–4.CrossRefGoogle Scholar
  13. 13.
    Samaras K, Marel GM. Failure of plasmapheresis, corticosteroids and thionamides to ameliorate a case of protracted amiodarone-induced thyroiditis. Clin Endocrinol. 1996;45:365–8.CrossRefGoogle Scholar
  14. 14.
    Noh KW, Seon CS, Choi JW, et al. Thyroid storm and reversible thyrotoxic cardiomyopathy after ingestion of seafood stew thought to contain marine neurotoxin. Thyroid. 2011;21:679–82.CrossRefGoogle Scholar
  15. 15.
    Fujio S, Ashari HM, Yamahata H, Moinuddin FM, et al. Thyroid storm induced by TSH-secreting pituitary adenoma: a case report. Endocr J. 2014;61:1131–6.CrossRefGoogle Scholar
  16. 16.
    Riis AL, Gravholt CH, Djurhuus CB, et al. Elevated regional lipolysis in hyperthyroidism. J Clin Endocrinol Metab. 2002;87:4747–53.CrossRefGoogle Scholar
  17. 17.
    Aiello DP, DuPlessis AJ, Pattishall EGIII, et al. Thyroid storm presenting with coma and seizures. Clin Pediatr (Phila). 1989;28:571–4.CrossRefGoogle Scholar
  18. 18.
    Lee TG, Ha CK, Lim BH. Thyroid storm presenting as status epilepticus and stroke. Postgrad Med J. 1997;73:61.PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Dai A, Wasay M, Dubey N, et al. Superior sagittal sinus thrombosis secondary to hyperthyroidism. J Stroke Cerebrovasc Dis. 2000;9:89–90.CrossRefGoogle Scholar
  20. 20.
    Lu KC, Hsu YJ, Chiu JS, et al. Effects of potassium supplementation on the recovery of thyrotoxic periodic paralysis. Am J Emerg Med. 2004;22:544–7.CrossRefGoogle Scholar
  21. 21.
    Feroza M, May H. Apathetic thyrotoxicosis. Int J Clin Pract. 1997;51:332–3.Google Scholar
  22. 22.
    van Hoek I, Daminet S. Interactions between thyroid and kidney function in pathological conditions of these organ systems: a review. Gen Comp Endocrinol. 2008;160:205–15.CrossRefGoogle Scholar
  23. 23.
    Goswami R, Seth A, Goswami AK, et al. Prevalence of enuresis and other bladder symptoms in patients with active Graves’ disease. Br J Urol. 1997;804:563–6.CrossRefGoogle Scholar
  24. 24.
    Kahara T, Yoshizawa M, Nakaya I, et al. Thyroid crisis following interstitial nephritis. Intern Med. 2008;47:1237–40.CrossRefGoogle Scholar
  25. 25.
    Jao YT, Chen Y, Lee WH, et al. Thyroid storm and ventricular tachycardia. South Med J. 2004;976:604–7.CrossRefGoogle Scholar
  26. 26.
    Daly MJ, Wilson CM, Dolan SJ, et al. Reversible dilated cardiomyopathy associated with post-partum thyrotoxic storm. QJM. 2009;102:217–9.CrossRefGoogle Scholar
  27. 27.
    Opdahl H, Eritsland J, Sovik E. Acute myocardial infarction and thyrotoxic storm—a difficult and dangerous combination. Acta Anaesthesiol Scand. 2005;49:707–11.CrossRefGoogle Scholar
  28. 28.
    Lee SM, Jung TS, Hahm JR, et al. Thyrotoxicosis with coronary spasm that required coronary artery bypass surgery. Intern Med. 2007;46:1915–8.CrossRefGoogle Scholar
  29. 29.
    Liu YC, Tsai WS, Chau T, et al. Acute hypercapnic respiratory failure due to thyrotoxic periodic paralysis. Am J Med Sci. 2004;327:264–7.CrossRefGoogle Scholar
  30. 30.
    Mezosi E, Szabo J, Nagy EV, et al. Nongenomic effect of thyroid hormone on free-radical production in human polymorphonuclear leukocytes. J Endocrinol. 2005;185:121–9.CrossRefGoogle Scholar
  31. 31.
    Luong KV, Nguyen LT. Hyperthyroidism and asthma. J Asthma. 2000;37:125–30.CrossRefGoogle Scholar
  32. 32.
    Barczynski M, Thor P. Reversible autonomic dysfunction in hyperthyroid patients affects gastric myoelectrical activity and emptying. Clin Auton Res. 2001;114:243–9.CrossRefGoogle Scholar
  33. 33.
    Bhattacharyya A, Wiles PG. Thyrotoxic crisis presenting as acute abdomen. J R Soc Med. 1997;90:681–2.PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Cansler CL, Latham JA, Brown PM Jr, et al. Duodenal obstruction in thyroid storm. South Med J. 1997;90:1143–16.CrossRefGoogle Scholar
  35. 35.
    Leow MK, Chew DE, Zhu M, et al. Thyrotoxicosis and acute abdomen: still as defying and misunderstood today? Brief observations over the recent decade. QJM. 2008;101:943–7.CrossRefGoogle Scholar
  36. 36.
    Homonick M, Gessl A, Ferlitsch A, et al. Altered platelet plug formation in hyperthyroidism and hypothyroidism. J Clin Endocrinol Metab. 2007;92:3006–12.CrossRefGoogle Scholar
  37. 37.
    Romualdi E, Squizzato A, Ageno W. Venous thrombosis: a possible complication of overt hyperthyroidism. Eur J Intern Med. 2008;19:386–7.CrossRefGoogle Scholar
  38. 38.
    Pekdemir M, Yilmaz S, Ersel M, et al. A rare cause of headache; cerebral venous sinus thrombosis due to hyperthyroidism. Am J Emerg Med. 2008;26:383.CrossRefGoogle Scholar
  39. 39.
    Osman F Gamma MD, Sheppard MC, et al. Clinical review 142: cardiac dysrhythmias and thyroid dysfunction: the hidden menace? J Clin Endocrinol Metab. 2002;87:963–37.CrossRefGoogle Scholar
  40. 40.
    Squizzato A, Gerdes VE. Thyroid disease and haemostasis: a relationship with clinical implications? Thromb Haemost. 2008;100:727–8.CrossRefGoogle Scholar
  41. 41.
    Lippi G, Franchini M, Targher G, et al. Hyperthyroidism is associated with shortened APTT and increased fibrinogen values in a general population of unselected outpatients. J Thromb Thrombolysis. 2008;28:362–5.CrossRefGoogle Scholar
  42. 42.
    Wartofsky L. The low T3 or ‘sick euthyroid syndrome’: update 1994. In: Braverman LE, Refetoff S, editors. Endocrine reviews monographs. 3. Clinical and molecular aspects of diseases of the thyroid. Bethesda: The Endocrine Society; 1994. p. 248–51.Google Scholar
  43. 43.
    Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin N Am. 1993;22:263–77.CrossRefGoogle Scholar
  44. 44.
    Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. 2012;22:593–646.CrossRefGoogle Scholar
  45. 45.
    Wartofsky L. Clinical criteria for the diagnosis of thyroid storm. Thyroid. 2012;22:659–60.CrossRefGoogle Scholar
  46. 46.
    Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. J Clin Endocrinol Metab. 2015;100:451–9.CrossRefGoogle Scholar
  47. 47.
    Kobayashi C, Sasaki H, Kosuge K, et al. Severe starvation hypoglycemia and congestive heart failure induced by thyroid crisis, with accidentally induced severe liver dysfunction and disseminated intravascular coagulation. Intern Med. 2005;44:234–9.CrossRefGoogle Scholar
  48. 48.
    Bahn Chair RS, Burch HB, Cooper DS, et al. American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21:593–646.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Nareem N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab. 1982;54:180–1.CrossRefGoogle Scholar
  50. 50.
    Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid. 1995;5(5):403.CrossRefGoogle Scholar
  51. 51.
    Zweig SB, Schlosser JR, Thomas SA, et al. Rectal administration of propylthiouracil in suppository form in patients with thyrotoxicosis and critical illness: case report and review of literature. Endocr Pract. 2006;12:43–7.CrossRefGoogle Scholar
  52. 52.
    Ogiso S, Inamoto S, Hata H, et al. Successful treatment of gastric perforation with thyrotoxic crisis. Am J Emerg Med. 2008;26:3–4.CrossRefGoogle Scholar
  53. 53.
    Thomas DJ, Hardy J, Sarwar R, et al. Thyroid storm treated with intravenous methimazole in patients with gastrointestinal dysfunction. Br J Hosp Med (Lond). 2006;67:492–3.CrossRefGoogle Scholar
  54. 54.
    Weissel M. Withdrawal of the parenterally applicable form of thyrostatic drugs in Austria. Thyroid. 2005;15:1203.CrossRefGoogle Scholar
  55. 55.
    Sowiński J, Junik R, Gembicki M. Effectiveness of intravenous administration of methimazole in patients with thyroid crisis. Endokrynol Pol. 1988;39:67–73.Google Scholar
  56. 56.
    Wartofsky L, Ransil BJ, Ingbar SH. Inhibition by iodine of the release of thyroxine from the thyroid glands of patients with thyrotoxicosis. J Clin Invest. 1970;49:78–86.PubMedCentralCrossRefPubMedGoogle Scholar
  57. 57.
    Boehm TM, Burman KD, Barnes S, et al. Lithium and iodine combination therapy for thyrotoxicosis. Acta Endocrinol. 1980;94:174–83.CrossRefGoogle Scholar
  58. 58.
    Reed J, Bradley EL III. Postoperative thyroid storm after lithium preparation. Surgery. 1985;98:983–6.Google Scholar
  59. 59.
    Vyas AA, Vyas P, Fillipon NL, et al. Successful treatment of thyroid storm with plasmapheresis in a patient with methimazole-induced agranulocytosis. Endocr Pract. 2010;16:673–6.CrossRefGoogle Scholar
  60. 60.
    Ozbey N, Kalayoglu-Besisik S, Gul N, et al. Therapeutic plasmapheresis in patients with severe hyperthyroidism in whom antithyroid drugs are contraindicated. Int J Clin Pract. 2004;58:554–8.CrossRefGoogle Scholar
  61. 61.
    Scholz GH, Hagemann E, Arkenau C, Engelmann L, Lamesch P, et al. Is there a place for thyroidectomy in older patients with thyrotoxic storm and cardiorespiratory failure? Thyroid. 2003;13:933–40.CrossRefGoogle Scholar
  62. 62.
    Ezer A, Caliskan K, Parlakgumus A, et al. Preoperative therapeutic plasma exchange in patients with thyrotoxicosis. J Clin Apher. 2009;24:111–4.CrossRefGoogle Scholar
  63. 63.
    Enghofer M, Badenhoop K, Zeuzem S, et al. Fulminant hepatitis A in a patient with severe hyperthyroidism; rapid recovery from hepatic coma after plasmapheresis and total thyroidectomy. J Clin Endocrinol Metab. 2000;85:1765–9.CrossRefGoogle Scholar
  64. 64.
    Burman KD, Yeager HC, Briggs WA, et al. Resin hemoperfusion: a method of removing circulating thyroid hormones. J Clin Endocrinol Metab. 1976;42:70–8.CrossRefGoogle Scholar
  65. 65.
    Candrina R, DiStefano O, Spandrio S, et al. Treatment of thyrotoxic storm by charcoal plasmaperfusion. J Endocrinol Investig. 1989;12:133–4.CrossRefGoogle Scholar
  66. 66.
    Solomon BL, Wartofsky L, Burman KD. Adjunctive cholestyramine therapy for thyrotoxicosis. Clin Endocrinol. 1993;38:39–43.CrossRefGoogle Scholar
  67. 67.
    Hughes G. Management of thyrotoxic crisis with a beta-adrenergic blocking agent (pronethalol). Br J Clin Pract. 1966;20:579–81.Google Scholar
  68. 68.
    Feely J, Forrest A, Gunn A, et al. Propranolol dosage in thyrotoxicosis. J Clin Endocrinol Metab. 1980;51:658–61.CrossRefGoogle Scholar
  69. 69.
    Rubenfeld S, Silverman VE, Welch KMA, et al. Variable plasma propranolol levels in thyrotoxicosis. N Engl J Med. 1979;300:353–4.CrossRefGoogle Scholar
  70. 70.
    Wiersinga WM. Propranolol and thyroid hormone metabolism. Thyroid. 1991;1:273–7.CrossRefGoogle Scholar
  71. 71.
    Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med. 1991;9:232–4.CrossRefGoogle Scholar
  72. 72.
    Knighton JD, Crosse MM. Anaesthetic management of childhood thyrotoxicosis and the use of esmolol. Anaesthesia. 1997;52:67–70.CrossRefGoogle Scholar
  73. 73.
    Yamashita Y, Iguchi M, Nakatani R, Usui T, Takagi D, et al. Thyroid storm with heart failure treated with a short-acting beta-adrenoreceptor blocker, Landiolol hydrochloride. Intern Med. 2015;54(13):1633–7.CrossRefGoogle Scholar
  74. 74.
    Kidess AJ, Caplan RH, Reynertson MD, et al. Recurrence of 131 I induced thyroid storm after discontinuing glucocorticoid therapy. Wis Med J. 1991;90:463–5.Google Scholar
  75. 75.
    Kawakami-Tani T, Fukawa E, Tanaka H, et al. Effect of alpha hydroxyvitamin D3 on serum levels of thyroid hormones in hyperthyroid patients with untreated Graves’ disease. Metabolism. 1997;46:1184–8.CrossRefGoogle Scholar
  76. 76.
    Benvenga S, Lapa D, Cannavo S, et al. Successive thyroid storms treated with l -carnitine and low doses of methimazole. Am J Med. 2003;115:417–8.CrossRefGoogle Scholar
  77. 77.
    Benvenga S, Ruggeri RM, Russo A, et al. Usefulness of l-carnitine, a naturally occurring peripheral antagonist of thyroid hormone action, in iatrogenic hyperthyroidism: a randomized, double-blind, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2001;86:3579–94.CrossRefGoogle Scholar
  78. 78.
    Bennett MH, Wainwright A. Acute thyroid crisis on induction of anesthesia. Anaesthesia. 1989;44:28–30.CrossRefGoogle Scholar
  79. 79.
    Shimoda Y, Satoh T, Takahashi H, Katano-Toki A, Ozawa A, 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. Endocr J. 2014;61:691–6.CrossRefGoogle Scholar
  80. 80.
    Jiang Y-Z, Hutchinson KA, Bartelloni P, Manthous C. Thyroid storm presenting as multiple organ dysfunction syndrome. Chest. 2000;118:877–9.CrossRefGoogle Scholar
  81. 81.
    Kofinas JD, Kruczek A, Sample J, Eglinton GS. Thyroid storm-induced multi-organ failure in the etting of gestational trophoblastic disease. J Emerg Med. 2015;48:35–8.CrossRefGoogle Scholar
  82. 82.
    Chong HW, See KC, Phua J. Thyroid storm with multiorgan failure. Thyroid. 2010;20:333–6.CrossRefGoogle Scholar
  83. 83.
    Dillman WH. Thyroid storm. Curr Ther Endocrinol Metab. 1997;6:81–5.Google Scholar
  84. 84.
    Tietgens ST, Leinung MC. Thyroid storm. Med Clin North Am. 1995;79:169–84.CrossRefGoogle Scholar
  85. 85.
    Leow MK, Loh KC. Fatal thyroid crisis years after two thyroidectomies for Graves’ disease: is thyroid tissue auto transplantation for postthyroidectomy hypothyroidism worthwhile? J Am Coll Surg. 2002;195:434–5.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Leonard Wartofsky
    • 1
    • 2
    Email author
  • Joanna Klubo-Gwiezdzinska
    • 1
    • 3
  1. 1.Georgetown University School of MedicineWashington, DcUSA
  2. 2.Thyroid Cancer Research UnitMedStar Health Research InstituteWashington, DCUSA
  3. 3.National Institutes of Health—National Institute of Diabetes and Digestive and Kidney DiseaseBethesdaUSA

Personalised recommendations