Life-threatening exacerbation of thyrotoxicosis with multi-organ decompensation.
Causes
- • Untreated Graves
- • Thyroid surgery, RAI
- • Infection, trauma, MI
- • Iodine load (contrast)
Clinical features
- • Fever >38.5
- • Tachycardia, AF, heart failure
- • Agitation, delirium, seizure
- • Vomiting, diarrhoea, jaundice
Investigations
- • TSH suppressed, free T4/T3 raised
- • FBC, U&E, LFT, glucose
- • ECG, CXR, septic screen
Diagnosis
- • Burch-Wartofsky score ≥45 highly suggestive
Differential diagnosis
- • Sepsis
- • Sympathomimetic toxicity
- • Phaeochromocytoma
- • Malignant hyperthermia
Management
- • ICU admission
- • Cooling, IV fluids, treat precipitant
- • Propranolol 1–2 mg IV slow (or 60–80 mg PO q4h)
- • Propylthiouracil 200 mg q4h then Lugol's iodine 1 h later
- • Hydrocortisone 100 mg IV q8h
Drug therapy
- • PTU 200 mg q4h
- • Hydrocortisone 100 mg q8h
- • Propranolol 60–80 mg PO q4h
- • Lugol's iodine 5 drops q6h (>1 h after PTU)
Complications
- • Heart failure
- • Arrhythmia
- • Death (10–30%)
Clinical pearls
- • Always give thionamide BEFORE iodine
Related in WardRound
Educational — verify locally.
