Thyroid Storm Induced by Trauma: A Challenging Combination

Thyroid storm in the trauma patient is a life-threatening, but rare, occurrence.

Trauma is rarely an inciting factor in thyroid storm and there are few cases described in
the literature. Thyroid storm presents a challenge to diagnose in the trauma patient due
to the similarity of many of the presenting symptoms. Thyroid storm can be precipitated
by acute illness or infection, surgery, medications, pregnancy, trauma, emotional stress,
or iodine-containing contrast agents. As thyroid storm progresses untreated, it can lead
to multisystem organ failure, shock, and death.
Trauma can be an inciting event in the development of thyroid storm but is rarely
described in the literature. Careful attention to patient history is critical to an early
diagnosis of thyroid storm. The treatment of thyroid storm must be aggressive and
initiated promptly to avoid mortality. The primary goals of medical therapy are to
decrease thyroid hormone production, block the release of thyroid hormone, decrease
the peripheral conversion of T4 to the more active form of T3, and decrease
enterohepatic circulation of thyroid hormones. In conclusion, thyroid storm in the trauma
patient is a rare event with a high mortality rate.

Davis, S., M.D., McIntyre, R., M.D., Cribari, C., M.D., & Dunn, J., M.D. (2018). Thyroid storm induced
by trauma: A challenging combination. The American Surgeon, 84(2), E44-E46. Retrieved from
https://www.proquest.com/scholarly-journals/thyroid-storm-induced-trauma-
challenging/docview/2012900727/se-2?accountid=31259
 The Perfect Storm: A Case of Ischemic Stroke in the Setting of
Thyroid Storm

Thyroid storm is a life-threatening condition due to uncontrolled hyperthyroid

state with an overall mortality as high as 10% to 60%. It can be precipitated by a variety
of events, including infection, surgery, trauma, iodine load, and medication non-
compliance. In these patients, there are increased rates of cardiomyopathy,
cardiovascular disease, and arrhythmias, particularly atrial fibrillation when compared to
the general population. Thyroid storm coexisting with ischemic stroke is a rare
presentation. In these scenarios, ischemic stroke can either act as the acute illness
precipitating the thyroid storm or can be the direct result of the storm. Thyroid storm is a
rare medical emergency resulting in extreme excess of circulating thyroid hormones in a
state known as thyrotoxicosis. Hyperthyroidism may result from increased production of
thyroid hormones or from exogenous thyroid hormones
Timely diagnosis of thyroid storm is challenging and is often missed due to non-
specific symptoms, which reflect an increased metabolic state. Ischemic stroke
presenting with thyroid storm is a rare occurrence. Ischemic stroke can be both the
cause and the effect of the thyroid storm. Ischemic stroke as a result of thyroid storm
has two possible mechanisms: atrial fibrillation and hypercoagulable state. After the
treatment of inciting illness, successful treatment of thyroid storm is dependent on early
reduction of thyroid hormone production and decreased extrathyroidal conversion of T4
to T3. PTU and methimazole are the mainstays in therapy and act to decrease follicular
growth and reduce thyroid peroxidase synthesis, thereby decreasing the synthesis of T4
and T3.

Non-radioactive iodide may also be considered as it can decrease thyroid

hormone production by causing plasma iodide levels to reach a threshold wherein
iodide is unable to bind to thyroglobulin in the thyroid gland. Additional reduction of
extra-thyroidal conversion of T4 to T3 can be aided by glucocorticoids, which
additionally act in the prevention of adrenal insufficiency that occurs at increased rates
in thyroid storm patients. In emergent cases, thyroidectomy is considered only after all
attempts at euthyroidism through medical management have failed as surgery can
precipitate additional thyroid storm. Correctly diagnosing thyroid storm in patients with
stroke and without a known diagnosis of hyperthyroidism remains challenging due to its
clinical overlap with other medical conditions. In the case of acute stroke with atrial
fibrillation, it is imperative that thyrotoxicosis always be considered as immediate
initiation of medical therapy to control thyroid storm can limit the morbidity and mortality.
 Snyder, S., & Joseph, M. (2020). The perfect storm: A case of ischemic stroke in the setting of
thyroid storm.  Cureus,  12(5) doi:http://dx.doi.org/10.7759/cureus.7992

Diagnosis and Comprehensive Management of Thyroid Storm in

Pregnancy : A Case Report

Thyroid storm is a rare serious complication in hyperthyroidism patients. The

adult mortality rate in the thyroid storm is 10-20% due to the late diagnostic and
treatment. 1,2,3 Principle of thyroid storm management in pregnancy are reducing the
synthesis and secretion of thyroid hormones, decreasing the peripheral effects of
thyroid hormone, inhibiting the conversion of T4 to T3, therapy to prevent systemic
decompensation, trigger disease therapy, pregnancy management and supportive
therapy. Additional diagnosis of Pulmonology Departement was Community Acquired
Pneumonia based on clinical finding of cough, fever, ronkhi in both lung suspected of
triggering a thyroid storm. The problem of diagnosis in these patients is actually
diagnosis of thyroid storm not immediately enforced at secondary hospitals due to the
disguised of thyroid crisis diagnostic by ADHF symptoms, acute pulmonary edema and
severe preeclampsia.

Theoretical pregnancy will lead to increased concentration of Thyroid binding

globulin resulting in the production of thyroid hormone outside the thyroid gland
increases resulting in total increase of T4 and T3.4,5 T4 metabolism increases in the
second and third trimesters, due to increased deiodination of placenta type II and type
III, which increases the conversion of T4 metabolism. In theory the diagnostic flow of
thyroid crisis is based on clinical findings of fever, tachycardia, signs and symptoms of
heart failure, decreased awareness or seizures, gastrointestinal disorders, history of
lack hyperthyroid medication, family history with hyperthyroidism, precipitating factors
such as infection, hypertension, trauma, history of surgery and signs of hyperthyroidism
such as: exopthalmus, goiter, bruit on the thyroid gland and tremors. Thyroid storm
diagnostic criteria using BW scores, involving several clinical components such as
thermoregulation, central nervous system, gastrointestinal, and
cardiovascular6Treatment of hyperthyroidism during pregnancy should consider
understanding of treatment, the choice of therapy for pregnant women and the goal of
therapy. PTU can inhibit thyroid hormone synthesis and has the effect of increasing the
peripheral conversion of T4 to T3. The lugol liquid was a saturated potassium iodide
liquid, where with a high iodine-containing preparation, uptake of iodine in the thyroid
gland can be decreased and then thyroid hormone secretion can be inhibited. If thyroid
storm occur in preterm pregnancy with not viable fetus, conservative treatment will be
considered after perform immediate treatment of thyroid storm.

Three months after treatment at the Sanglah General Hospital, TSHs and FT4
levels examination were performed on the mother and normal thyroid function was
obtained. Laboratory evaluations were performed at 3 months of age with normal range
value of TSH and FT4. Conclusion Thyroid storm is Endocrinology emergency
characterized by acute hypermetabolic with rapid deterioration of life-threatening
condition. The criteria for thyroid storm diagnosis by using BW scores, involving several
components such as thermoregulation, central nervous system, gastrointestinal, and
cardiovascular. Management of thyroid storm includes PTU, lugol solution given 1 hour
after PTU and dexamethasone whereas heart failure treatment can be given diuretics to
reduce fluid overload in other hand CAP treatement can be given antibiotic combination
like cefalosporin and macrolide group. To reduce the incidence rate of thyroid storm in
pregnancy, required thyroid hormone profile screening at antenatal care.

Prabawa, A., & Ketut, S. N. (2018). Diagnosis and comprehensive management of thyroid
storm in pregnancy : A case report. Biomedical & Pharmacology Journal,  11(3), 1329-1334.
doi:http://dx.doi.org/10.13005/bpj/1495
 Thyroid storm: Is there a role for thyroid function test?

Here we report a patient with TS, who did not respond clinically to the initial
treatment but post plasmapheresis, her thyroid function test improved. Her blood
investigations revealed increased white cell count, raised free thyroxine with
suppressed thyroid stimulating hormone, deranged liver, renal and coagulation profiles.
Due to poor response to the initial treatment, plasmapheresis was started on day 4 of
her admission. Despite being on maximal inotrope support, patient succumbed due to
multi-organ failure one day after plasmapheresis.

There are a few hypotheses regarding the pathogenesis of TS. Either there is
rapid increase in thyroid hormones, giving rise to an abrupt increase in intracellular
availability of free thyroid hormones, or, there is diminished physiological reserve due to
intercurrent illness. These two mechanisms will lead to imbalance of the normal thyroid
hormone homeostasis. The renal profile worsened from day 1 to 3, improving on day 4
post plasmapheresis but deteriorating again on day 5. The potassium level reduced
after plasmapheresis, probably due to the effect of replacement regimen using saline
and albumin. 6 Increasing trend of alanine aminotransferase, aspartate
aminotransferase and bilirubin indicated hepatocellular injury, which can be attributed to
the direct effect of increased thyroid hormones.

Management In the consensus for management of thyroid disorders in Malaysia,

the therapies used are specifically directed against the thyroid using ATD including
thionamides to block thyroid hormone synthesis followed by Lugol's iodine to prevent
thyroid hormone release. Rarely practised in Malaysia, plasmapheresis can be done in
life threatening cases or in patients with contraindication to thionamides. 2 As
recommended by the Japanese Thyroid Association and Japanese Endocrine Society
Taskforce Committee, it should be considered if there is no clinical improvement within
2448 hours of initial treatment. Biochemically her TFT improved, but because of MOF,
she succumbed a day after plasmapheresis. Plasmapheresis for TS is rarely done in
Malaysia2 and should be considered as an early treatment option in its management.

Ibrahim, T. Z., Thambiah, S. C., Samsudin, I. N., Nasuruddin, A. N., & Zakaria, M. H. (2019). Thyroid
storm: Is there a role for thyroid function test?  The Malaysian Journal of Pathology,  41(3), 355-358.
Retrieved from https://www.proquest.com/scholarly-journals/thyroid-storm-is-there-role-function-
test/docview/2352148321/se-2?accountid=31259
 Diagnosis and Comprehensive Management of Thyroid Storm in
Pregnancy : A Case Report

Thyroid storm is a rare serious complication in hyperthyroidism patients. The

adult mortality rate in the thyroid storm is 10-20% due to the late diagnostic and
treatment. 1,2,3 Principle of thyroid storm management in pregnancy are reducing the
synthesis and secretion of thyroid hormones, decreasing the peripheral effects of
thyroid hormone, inhibiting the conversion of T4 to T3, therapy to prevent systemic
decompensation, trigger disease therapy, pregnancy management and supportive
therapy. Additional diagnosis of Pulmonology Departement was Community Acquired
Pneumonia based on clinical finding of cough, fever, ronkhi in both lung suspected of
triggering a thyroid storm. The problem of diagnosis in these patients is actually
diagnosis of thyroid storm not immediately enforced at secondary hospitals due to the
disguised of thyroid crisis diagnostic by ADHF symptoms, acute pulmonary edema and
severe preeclampsia.
Theoretical pregnancy will lead to increased concentration of Thyroid binding
globulin resulting in the production of thyroid hormone outside the thyroid gland
increases resulting in total increase of T4 and T3.4,5 T4 metabolism increases in the
second and third trimesters, due to increased deiodination of placenta type II and type
III, which increases the conversion of T4 metabolism. In theory the diagnostic flow of
thyroid crisis is based on clinical findings of fever, tachycardia, signs and symptoms of
heart failure, decreased awareness or seizures, gastrointestinal disorders, history of
lack hyperthyroid medication, family history with hyperthyroidism, precipitating factors
such as infection, hypertension, trauma, history of surgery and signs of hyperthyroidism
such as: exopthalmus, goiter, bruit on the thyroid gland and tremors. Thyroid storm
diagnostic criteria using BW scores, involving several clinical components such as
thermoregulation, central nervous system, gastrointestinal, and cardiovascular6 Patient
have been through the diagnostic flow procedure as mentioned above and have BW
score: 55, where if a score> 45 apppropiate for thyroid crisis diagnostic. PTU can inhibit
thyroid hormone synthesis and has the effect of increasing the peripheral conversion of
T4 to T3. The lugol liquid was a saturated potassium iodide liquid, where with a high
iodine-containing preparation, uptake of iodine in the thyroid gland can be decreased
and then thyroid hormone secretion can be inhibited. If thyroid storm occur in preterm
pregnancy with not viable fetus, conservative treatment will be considered after perform
immediate treatment of thyroid storm.
Three months after treatment at the Sanglah General Hospital, TSHs and FT4
levels examination were performed on the mother and normal thyroid function was
obtained. Laboratory evaluations were performed at 3 months of age with normal range
value of TSH and FT4. Conclusion Thyroid storm is Endocrinology emergency
characterized by acute hypermetabolic with rapid deterioration of life-threatening
condition. The criteria for thyroid storm diagnosis by using BW scores, involving several
components such as thermoregulation, central nervous system, gastrointestinal, and
cardiovascular. Management of thyroid storm includes PTU, lugol solution given 1 hour
after PTU and dexamethasone whereas heart failure treatment can be given diuretics to
reduce fluid overload in other hand CAP treatement can be given antibiotic combination
like cefalosporin and macrolide group. To reduce the incidence rate of thyroid storm in
pregnancy, required thyroid hormone profile screening at antenatal care.

Prabawa, A., & Ketut, S. N. (2018). Diagnosis and comprehensive management of thyroid
storm in pregnancy : A case report.  Biomedical & Pharmacology Journal,  11(3), 1329-1334.
doi:http://dx.doi.org/10.13005/bpj/1495