Clinical Features and Hospital Outcomes in Thyroid Storm: A Retrospective Cohort Study

Context: Thyroid storm (TS) is a rare but life-threatening manifestation of thyrotoxicosis. Predictive features and outcomes remain incompletely understood, in part because studies comparing TS with hospitalized thyrotoxic patients have rarely been performed. Objectives: Our objectives were to compare the diagnosis and outcomes in TS versus hospitalized compensated thyrotoxic (CT) patients and to assess differences in diagnostic classification using the Burch-Wartofsky scores (BWSs) or Akamizu (Ak) criteria for identifying TS. Design, Setting, and Patients: This was a retrospective cohort study of hospitalized patients during a 6-year period at an academic tertiary hospital, with age >= 18 years, TSH <0.01 mIU/L, and clinically diagnosed TS or CT. Outcome Measures: In-patient mortality, hospital and intensive care unit length of stay, intubation, and ventilator duration were assessed. Results: Twenty-five TS and 125 CT patients were identified and analyzed. All but 1 TS patient received thionamides, beta-blockade, glucocorticoids, and iodides within 24 hours of diagnosis. CT patients received thionamides and beta-blockade alone. In the acute hospital setting, rates of fever (>100.4 degrees F), heart rate (>100 beats/min), altered mentation, and a precipitating event were all higher for TS than for CT patients. Altered mentation was the only clinical feature significantly different between TS and the subset of CT patients defined as TS by BWS or Ak criteria (P < .001). TS patients had greater in-patient mortality, hospital and intensive care unit length of stay, and ventilation requirements than CT patients. Conclusions: In acutely hospitalized thyrotoxic patients, the presence of central nervous system dysfunction distinguished clinically diagnosed TS from patients with BWS-or Ak-defined TS. Because TS patients had significantly worse outcomes in this study, thyrotoxic patients with possible TS and central nervous system dysfunction may derive the greatest benefit from aggressive supportive and TS-specific treatments.