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Hyperthyroidism, Thyroid Storm, and Graves Disease: Diagnosis and Differentials

Authors: Erik D. Schraga, MDAuthor Information and Disclosures

Contents

Clinical

History: The clinical presentation of hyperthyroidism ranges from an array of nonspecific historical features to an acute life-threatening event. Historical features common to hyperthyroidism and thyroid storm are numerous and represent a hypermetabolic state with increased beta-adrenergic activity.
  • Weight loss
    • Patients typically report an average loss of approximately 15% of their prior weight.
    • Basal metabolic rate is increased with a stimulation of lipolysis and lipogenesis.
  • Palpitations
  • Chest pain - Often occurs in the absence of cardiovascular disease
  • Psychosis
  • Menstrual irregularity
  • Disorientation
  • Tremor
  • Nervousness, anxiety, or emotional lability
  • Heat intolerance
  • Increased perspiration
  • Fatigue
  • Weakness - Typically affects proximal muscle groups
  • Edema
  • Dyspnea
  • Frequent bowel movements

Physical:

  • Fever
  • Tachycardia (often out of proportion to the fever)
  • Diaphoresis (often profuse)
  • Dehydration secondary to GI losses and diaphoresis
  • Warm, moist skin
  • Widened pulse pressure
  • Congestive heart failure (may be a high output failure)
  • Thyromegaly
    • Nontender, diffuse enlargement in Graves disease
    • Tender, diffusely enlarged gland in thyroiditis
    • Thyroid nodules, either single or multinodular goiter
  • Exophthalmos
  • Shock
  • Atrial fibrillation
    • Typically in elderly patients
    • May be refractory to attempted rate control with digitalis
    • Converts after antithyroid therapy in 20-50% of patients
  • Myopathy
  • Thyroid bruit - Relatively specific for thyrotoxicosis
  • Fine, resting tremor

Causes: Hyperthyroidism results from numerous etiologies, including autoimmune, drug-induced, infectious, idiopathic, iatrogenic, and malignancy.

  • Autoimmune
    • Graves disease
    • Chronic thyroiditis (Hashimoto thyroiditis) - Although the primary cause of hypothyroidism, the disease process occasionally presents initially with thyrotoxicosis
    • Subacute thyroiditis (de Quervain thyroiditis) - Diffuse, painful inflammation of the thyroid producing a transient state leakage of stored hormone
    • Postpartum thyroiditis - Presents similarly to subacute thyroiditis 2-6 months postpartum but typically painless with mild symptoms
  • Drug-induced
    • Iodine-induced - Occurs after administration of either supplemental iodine to those with prior iodine deficiency or pharmacologic doses of iodine (contrast media, medications) in those with underlying nodular goiter
    • Amiodarone - Its high iodine content is primarily responsible for producing a hyperthyroid state, though the medication may itself induce autoimmune thyroid disease.
  • Infectious
    • Suppurative thyroiditis - Often bacterial, results in a painful gland commonly in those with underlying thyroid disease or in immunocompromised individuals

    • Postviral thyroiditis
  • Idiopathic
    • Toxic multinodular goiter - The second most common cause of hyperthyroidism, characterized by functionally autonomous nodules, typically after age 50 years
  • Iatrogenic
    • Thyrotoxicosis factitia - A psychiatric condition in which high quantities of exogenous thyroid hormone are consumed
    • Surgery - Now uncommon secondary to preventative measures, manipulation of the thyroid gland during thyroidectomy historically caused a flood of hormone release, often resulting in highly toxic blood levels
  • Malignancy
    • Toxic adenoma - A single, hyperfunctioning nodule within a normally functioning thyroid gland commonly among patients in their 30s and 40s
    • Thyrotropin-producing pituitary tumors

    • Struma ovarii - Ovarian teratoma with ectopic thyroid tissue
  • Thyroid storm can be triggered by many different events, classically in patients with underlying Graves disease or toxic multinodular goiter.
    • Infection

    • Surgery

    • Cardiovascular events

    • Toxemia of pregnancy

    • Diabetic ketoacidosis, hyperosmolar coma, and insulin-induced hypoglycemia

    • Thyroidectomy

    • Discontinuation of antithyroid medication

    • Radioactive iodine

    • Vigorous palpation of the thyroid gland in hyperthyroid patients

Differentials

Anxiety
Congestive Heart Failure and Pulmonary Edema
Delirium Tremens
Diabetes Mellitus, Type 1 - A Review
Diabetes Mellitus, Type 2 - A Review
Heat Exhaustion and Heatstroke
Munchausen Syndrome
Neuroleptic Malignant Syndrome
Panic Disorders
Shock, Septic
Toxicity, Anticholinergic
Toxicity, Selective Serotonin Reuptake Inhibitor
Toxicity, Sympathomimetic
Withdrawal Syndromes


Other Problems to be Considered:

Psychosis
Anxiety
Malignancy
Pregnancy
Pheochromocytoma

Workup

Lab Studies:

  • Thyroid function studies confirm the diagnosis in the appropriate clinical setting.
    • Elevation of free T4 and low to undetectable TSH levels are diagnostic of thyrotoxicosis.
    • Excessive TSH levels in the setting of elevated free T4 indicate hyperthyroidism of pituitary origin.
    • There is little utility in obtaining total T4 levels, as variations in serum thyroid-binding proteins alter the ability to interpret results.
    • Particularly in thyroid storm, the diagnosis must be made on the basis of the clinical examination as rapid assays are not universally available.
    • Thyroid function studies do not distinguish thyrotoxicosis from thyroid storm; however, several laboratory abnormalities may be encountered in thyroid storm.
  • Hyperglycemia
  • Hypercalcemia
  • Hepatic function abnormalities
  • Low serum cortisol
  • Leukocytosis
  • Hypokalemia (in thyrotoxic periodic paralysis)

Imaging Studies:

  • Chest radiography may identify congestive heart failure or pulmonary infections, often associated with progression to thyroid storm.
  • Nuclear thyroid scan
    • Diffuse uptake in Graves disease
    • Focal uptake in toxic nodular thyroiditis

Other Tests:

  • Electrocardiogram
    • Sinus tachycardia most common
    • Atrial fibrillation (often in elderly patients)
    • Complete heart block (rare)
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Hyperthyroidism, Thyroid Storm, and Graves Disease excerpt

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Author Information and Disclosures

Author: Erik D. Schraga, MD, Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center

Coauthor(s): Craig A. Manifold, DO, Associate Program Director, Department of Emergency Medicine, Wilford Hall Medical Center

Erik D Schraga, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents' Association

Editor Information

Robin R Hemphill, MD, MPH, Associate Professor, Director, Disaster Preparedness, Department of Emergency Medicine, Vanderbilt University Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Howard A Bessen, MD, Professor of Medicine, UCLA School of Medicine; Program Director, Department of Emergency Medicine, Harbor-UCLA Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

 
 
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