What exactly is thyroid storm?
How dangerous is this condition and how will you know if you have it?
This post will concentrate on this medical condition and teach you everything you need to know about it.
Including the difference between regular hyperthyroidism and thyroid storm, the difference in symptoms, how to prevent it from happening, and more:
What is the Difference Between Thyrotoxicosis and Thyroid Storm?
It’s important to distinguish between the two conditions known as thyrotoxicosis and thyroid storm.
Many people believe they are in a “thyroid storm” when in reality they are suffering from the symptoms of hyperthyroidism, too much thyroid hormone in their body, or thyrotoxicosis.
Thyroid storm, on the other hand, is a very serious medical emergency that requires immediate treatment or the result may be death.
It helps to think about hyperthyroidism on a spectrum.
On one side of the spectrum, you have a mild amount of excess thyroid hormone which leads to symptoms such as weight loss, diarrhea, and heart palpitations.
On the complete opposite side, you have the condition known as thyroid storm which may ultimately lead to serious conditions such as liver failure, heart failure, and even death. (1)
So while these two conditions (thyrotoxicosis and thyroid storm) may be caused by the same condition they represent different intensities of the same disease.
The good news is that it’s not likely that you are going to “miss” the symptoms associated with a thyroid storm.
Most people who experience these symptoms will either be taken straight to the emergency department or to their doctor which usually leads to rapid diagnosis.
Even when taken to the hospital, though, mortality rates associated with thyroid storm can be as high as 10-20%. (2)
This means that even with treatment, up to 10-20% of people who have thyroid storm may still die as a result of their condition.
Because of this high mortality rate early diagnosis is key to preventing death and serious complications of this disease.
Some causes of thyroid storm result from untreated thyroid conditions such as Graves’ disease but can be the result of any cause of hyperthyroidism (remember that many different conditions can cause hyperthyroidism!).
These conditions are important to discuss because they may slowly progress, over a period of weeks to months, to thyroid storm if they are not treated or addressed or if they are ignored.
Some patients, perhaps unknowingly, may put themselves at increased risk for thyroid storm as they pursue natural therapies for hyperthyroidism.
Other causes of thyroid storm occur very rapidly, which means you can’t predict that they will happen.
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Symptoms Associated with Thyroid Storm
How do you know when you progress from thyrotoxicosis to thyroid storm?
Are there certain symptoms associated with thyroid storm which can help you determine if you need to go to the hospital?
The short answer is yes.
As you might suspect, the symptoms of thyroid storm tend to mimic those associated with hyperthyroidism but tend to be on the extreme side of the spectrum.
Thyroid storm can be diagnosed with a combination of your clinical appearance and your lab work.
Symptoms commonly associated with thyroid storm include:
- Fever (or thermoregulatory dysfunction)
- Rapid heart rate (tachycardia)
- Rapid development of heart conditions such as heart failure, heart attack, or atrial fibrillation
- Swelling or edema of the extremities
- Neurological dysfunction ranging from agitation to seizures or coma
- Gastrointestinal issues ranging from diarrhea to jaundice or liver failure
You are given points based on the severity of the symptoms listed above. (3)
If your “score” is a high enough score with all of your points (meaning that your symptoms are severe) then you may be treated for thyroid storm.
Mild symptoms, such as a slightly elevated heart rate, a slightly elevated body temperature, and the absence of organ damage may simply represent a hyperthyroid state and not thyroid storm.
Even if you aren’t sure if your symptoms “classify” as thyroid storm you should still be evaluated by your doctor if you notice that your symptoms are worsening.
Lab Testing
Lab testing can also help to identify the presence of this condition.
Testing should focus on evaluating thyroid function with the use of free thyroid hormones, especially free T3 and free T4 (in addition to TSH).
Thyroid lab testing, during a thyroid storm, will show an extreme elevation in free T3 and a very low TSH.
These are all indicators that the amount of thyroid hormone that your body is producing is excessive for what it needs and that it is not “obeying” the normal feedback and regulatory loops in place.
If end-organ damage is suspected then assessing for these conditions is also helpful.
This can be done with routine tests such as liver function testing, pancreatic testing, cardiac enzyme testing, and so on.
If positive, these tests may indicate organ and tissue damage which may require treatment above and beyond blocking thyroid function (more on that below).
What Causes Thyroid Storm?
Thyroid storm occurs when your organs and tissues are exposed to a critical mass of thyroid hormone.
Thyroid hormone acts to increase the amount of energy that your tissues burn by increasing oxygen consumption.
As T3 and T4 levels continually rise inside your tissues, these tissues continually work harder and harder.
Once the levels reach a critical point your tissues begin to die due to overexertion and that’s when many of the symptoms of thyroid storm kick in.
Your body and cells have the ability to tolerate some amount of excess thyroid hormone, but once the tissues start to die then the problems begin.
But what causes thyroid storm to begin?
Most of the time this condition is the result of undertreated or untreated Graves’ disease.
Remember:
Graves’ disease and hyperthyroidism are both caused by excess thyroid hormone in the body.
The treatment for these conditions is to slow down the production of thyroid hormone.
If you fail to do this, or you don’t do it adequately with therapies and medications, then your risk of developing a thyroid storm increases over time.
Any condition that causes hyperthyroidism can result in thyroid storm, but it appears to be the most common in Graves’.
Thyroid storm can also happen abruptly in patients who have hyperthyroidism when they also are dealing with some other acute medical condition. (4)
So if you have hyperthyroidism AND you have a heart attack (5), go into DKA (6), become pregnant (7), or experience massive trauma (8), then these conditions may “trigger” the transition from hyperthyroidism into thyroid storm.
Many of these conditions can’t be predicted, so you must be on high alert if you have hyperthyroidism and start to experience a worsening of your symptoms, especially if you also have another medical condition.
Treatment
Thyroid storm is a life-threatening medical emergency which means that if you have this condition you will require emergent medical attention.
A medical emergency is defined as any condition which may result in the death of the patient if not treated and diagnosed rapidly.
Other conditions that fit into the “medical emergency” category include heart attack and stroke.
This means that treatment is incredibly important and must be initiated shortly after diagnosis!
As you might suspect, the treatments for thyroid storm include those same treatments used for hyperthyroidism but in higher dosages.
The goal, when treating thyroid storm, is to address the excessively high levels of thyroid hormone in the body. (9)
This is accomplished by blocking the release of thyroid hormone from the thyroid gland, removing thyroid hormone from the bloodstream, and by preventing thyroid hormone from “activating” your cells.
All of these therapies are designed to help prevent further damage to your body.
Medications used to treat thyroid storm fit into the 5 “Bs”
- Block Synthesis (Use antithyroid drugs such as Methimazole or PTU which prevent your body from making more thyroid hormone).
- Block release (Using high doses of iodine can prevent your thyroid gland from releasing more thyroid hormone through the Wolff-Chaikoff effect).
- Block T4 to T3 conversion (By using high doses of steroids or PTU. These medications prevent your body from “activating” thyroid hormone).
- Beta-blockers (10) (Beta blockers are medications that can slow down the cellular effects of thyroid hormone and reduce heart rate and tremors).
- Block gastrointestinal circulation (Using binders such as cholestyramine prevent your own body from activating and reabsorbing thyroid hormone).
If you have a thyroid storm then you may be placed on several medications all at once, depending on the severity of your disease, and placed in an intensive care unit for frequent monitoring.
You can compare this treatment paradigm to hyperthyroidism which frequently only requires one medication such as methimazole. (11)
Other treatments may include supportive measures such as managing your body temperature and providing IV fluids, the replacement of electrolytes, and providing care to damaged organs.
Even with all of these therapies sometimes it’s not enough to block thyroid function.
In rare cases, a treatment known as plasmapheresis may be required. (12)
This treatment helps “clean” up your blood by taking the thyroid hormone out of your bloodstream.
This condition must be repeated several times if it is used.
Prognosis & Outcome
Prognosis refers to what kind of outlook you can expect after a disease.
While thyroid storm is a medical emergency and associated with up to 10-20% mortality, most people, if they seek medical attention quickly, should not experience long-term negative consequences of the disease.
It should never be ignored, however, that up to 10-20% of people who have this condition may die as a result.
With chances as high as these it’s best to practice prevention so you don’t have to worry about putting yourself in that type of condition.
How do you Prevent Thyroid Storm?
The best way to prevent this disease is by taking care of and managing your hyperthyroidism or Graves’ disease. (13)
That means taking your medication, eating healthy, taking supplements (if necessary), and monitoring your thyroid lab tests frequently.
If you do this you will be able to ensure that you are properly medicated and treated.
While you can’t necessarily predict that you will have a heart attack or some other precipitating cause of a thyroid storm, you can still do a lot to potentially reduce the likelihood of these diseases by leading a healthy lifestyle.
Managing your stress, exercising, and eating healthy are all ways to reduce the chance that you’ll have a serious medical condition.
Conclusion
Thyroid storm is a serious medical condition that requires immediate attention and medical care.
The sooner you get treatment the better because you may be able to reduce the amount of damage that occurs in your body.
This condition is usually triggered by an existing hyperthyroid condition which becomes exaggerated either due to under-treatment or to some other secondary medical condition.
The best “treatment” for this condition is to prevent it from occurring!
You can do this by monitoring your thyroid function, if you have hyperthyroidism, and by getting frequent lab tests.
Now I want to hear from you:
Are you concerned that you may have the symptoms of a thyroid storm?
Do you also have hyperthyroidism?
Are you being treated adequately?
Why or why not?
Leave your comments or questions below!
Thank you, Dr. Childs, for your informative article and dedication to our the medical field!
Hi Kellene,
No problem and glad you found it helpful!
Husband is in ICU for thyroid storm. He has been intubated twice now in a week or so (9 days running). Not sure how it started but he has stage 4 metastatic melanoma, was receiving immunotherapy Opdivo/Vervoy, and has had 2 brain surgeries (1 was to remove 2 tumors at the base in Jan. and 1 was a bleeding tumor in the frontal lobe in June.). He seemed to be doing well. He has had gamma knife in Feb which seemed to be doing the trick and another planned as soon as we can get him well enough to resume. MRIs show no new growths. He was brought to ER because he stopped eating, drinking, bathing and wanted to sleep all the time. He complained about his neck hurting really bad one day so I though we ought to go get it checked out. He was admitted that night and went into the storm the next day. Thanks for your article. I learned a lot while studying up on this very scary situation.
Hi Susan,
You’re welcome! And I’m sorry to hear about your situation but it sounds like your husband is in good hands in the ICU. My prayers are with you guys!
Hi Dr. Childs — I hope you see this question! My liver levels have been extremely elevated since November 2019.
I just turned 31 and am a female. Father has hypothyroidism.
In 2016 I had a parathyroidectomy for hyperparathyroidism/hypercalcemia. All tests have been normal. In January 2019 I went to a new, referred endocrinologist who put me on 75mcg of Levothyroxine because I complained on brain fog. My labs were normal still. 3 months later it showed I was Hypothyroid. Then after another 3 months the tests showed hyperthyroid (.006).
I got off the medication immediately as instructed. I switched to a new doctor right after that, and I am still (April 2020) hyperthyroid (.006 tsh) and currently have normal free t3 and t4 and have positive (63) thyroperoxidase antibodies.
My new doctor is trying to prescribe me Methimazole for hyperthyroidism (he said this would be for the rest of my life?!)…. but I’m convinced the Levothyroxine was the cause of the hyperthyroidism to begin with, so I’m hesitant to get on any medication again at this point.
What advice can you give me?
I’m scheduled to see him July 2020 and really want to avoid medication. We already did the iodine scan and it showed fine and I do not have any nodules. I feel “ok” for the most part at eat relatively healthy and exercise.
Sorry for the long post. Just really at a dead end.
I really don’t understand why you think there must be a hyperthyroid situation in the background. I am thinking quite the opposite?
While I doubt I have ever had a thyroid storm, over 18 years, I have now had at least 2 episodes (3 if the first was slight) of excessive thyroid function like thyrotoxicosis lasting 6 weeks or so, later followed by years of HYPOthyroidism (at least after the second episode: I had a TSH of 5.6 for a while, extreme sluggishness, no energy or motivation, constant indigestion, depression, COLD all the time… then for the subsequent 5 years, what feels to me like a moderately sluggish thyroid: TSH 2.2 or so, slight weight gain).
And now (end Jan 2021) this “acute” episode of thyrotoxicosis out of the blue (perhaps some viral intervention, but still…)
-5Kg in 2 weeks, body fat from 28% to 12% in 2 weeks, rash, nausea, fast heart and breathing rate, VERY LOW HRV, fatigue, heat intolerance (even in January with the heating off!),
I am dreading the other side of the curve. Anything I can do to avoid going HYPO again?
So I would expect others may have similar experiences… I am surely not a hyperthyroid person in general. And also thyroid antibody tests like TPO have always been negative.
Hello Dr. Childs
In 2020 I had a complete thyroidectomy for papillary cancer, metastatic to lymphnodes. I have had a very difficult time on Synthroid getting stabilization. I’ve been as high as 5.6 TSH and as low as 0.02 TSH in a matter of months. I always fear being so low because of thyroid storm….is this a legitimate fear? A medicine induced thyroid storm? I know my Dr wants to keep my TSH Low because I had cancer but it scares me and causes anxiety. Even though my numbers say I am hyperthyroid I do not have any symptoms. HR 60’s, BP is 117/70, temp is always low, I’ve gained 20lbs, I do have heat intolerance but that’s it. I read your blog all the time, searching for answers.
Hi Lacey,
Thyroid storm is very rare when using thyroid medications so I wouldn’t worry too much about that. Before you enter a thyroid storm you will feel hyperthyroid so they are usually warning signs that it is coming.
Hi Dr. Childs. I had my entire Thyroid removed because of a non cancerous lump14 years ago and have been on 150mg of Armour Thyroid pretty much the entire time. (allergic to synthetics) Over the years I have battled finding a doctor that will keep me at that dose because they think I am going to go into a thyroid storm. I find I have to keep my TSH very low and my Free T3 upper range and Free T4 at mid range in order to feel normal. I currently had my levels checked again in order to get my refills again. My new doctor is alarmed at the levels and wants to reduce my dose. I told her I have to keep my levels here but she thinks I am going to go into a thyroid storm with my TSH at a very low level. I was never Hypo or hyper before I had my thyroid removed. I have surgically induced hypothyroidism and I really need to reassure her that it is impossible for me to have a thyroid storm. Would you be able to write something on the reply stating that people that are on desiccated medications have to keep their TSH levels low and that the free T3 and Free T4 that is in the medication can lower the TSH levels when blood work is done? It is my understanding that this is the case. In order for me to feel normal and not bedridden my TSH levels have to be low. Thank you for any input or maybe direct me to some article that I can bring to her stating that I am not going to go into a Thyroid storm at these levels. Thank you!
Hi Kelli,
You may find the information in this article helpful: https://www.restartmed.com/low-tsh-vs-suppressed-tsh-on-thyroid-medication/
Dear Dr Childs,
1) Do most Doctors check iodine levels when a person is diagnosed with hypothyroidism? Ans. No. they disregard this and probably think one is arrogant for even asking for a lab test of the iodine level. (Been there, done that for myself and members of my family who all had low iodine by A.M.A. standards. My 25 year old son is regulating his thyroid levels to normal levels adding iodine 12.5 mg daily-approved by our progressive M.D.)
2)As TSH is a pituitary hormone, would intentional long term suppression of this hormone damage the pituitary eventually?
Hi Susan,
Unfortunately, all of the measurements of iodine are inaccurate so testing is usually meaningless and shouldn’t be used to determine iodine intake/dosing: https://www.restartmed.com/iodine-testing/
I also personally don’t recommend high dose iodine (12.5mg would qualify) for the reasons listed here: https://www.restartmed.com/high-dose-iodine/
I’m unaware of any studies which suggest that long-term TSH suppression negatively impacts pituitary function and it’s been my experience that pituitary function bounces back to baseline rather quickly once thyroid medication is stopped (assuming there aren’t any other issues preventing it from doing so).
I have no idea what is going on. I had breast cancer and radiation for this. All seemed to be going okay. Then blood work showed my thyroid turned hyper from hypo. I stopped taking the Synthroid but then my emotions were out of control and I cried all the time or felt irritated and angry. Last week I was so dizzy my team took me to emergency where I learned, my thyroid is dead and not putting out any hormone at all. So now I am back on 100mcg of Synthroid once a day. On top of this, I picked up a nasty chest infection while at the hospital so now who know what is wrong. I have hot flashes every hour over my whole body. I am so miserable but I can’t see the doctor til Monday morning.