Clinical Features and Hospital Outcomes in Thyroid Storm: A Retrospective Cohort Study
Abstract
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, β-blockade, glucocorticoids, and iodides within 24 hours of diagnosis. CT patients received thionamides and β-blockade alone. In the acute hospital setting, rates of fever (>100.4 °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.
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An additional 50 patients (40%) hospitalized with a clinical diagnosis of thyrotoxicosis without thyroid storm would have been diagnosed as having impending thyroid storm by the BWPS, which reinforces that a BWPS in the 25-44 range does not supplant clinical judgment in the selection of patients for aggressive therapy.
“However, an additional 50 patients (40%) hospitalized with a clinical diagnosis of thyrotoxicosis without thyroid storm would have been diagnosed as having impending thyroid storm by the BWPS, which reinforces that a BWPS in the 25-44 range does not supplant clinical judgment in the selection of patients for aggressive therapy.”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [226]
Data comparing the BWPS and JTA diagnostic systems suggest an overall agreement, but a tendency toward underdiagnosis using the JTA categories of TS1 and TS2 compared to a BWPS ≥45.
“Data comparing these two diagnostic systems suggest an overall agreement, but a tendency toward underdiagnosis using the JTA categories of TS1 and TS2, compared to a BWPS ‡45 (72,186,226,227).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [226]
Among 125 patients hospitalized with a clinical diagnosis of compensated thyrotoxicosis but not in thyroid storm, 27 (21.6%) had a BWPS ≥45, and 21 (16.8%) had a diagnosis category of either TS1 or TS2, suggesting similar rates of overdiagnosis with these two systems.
“Importantly, in the same series, among 125 patients hospitalized with a clinical diagnosis of compensated thyrotoxicosis but not in thyroid storm, 27 (21.6%)had a BWPS ‡45, and 21 (16.8%) had a diagnosis category of either TS1 or TS2, suggesting similar rates of overdiagnosis with these two systems.”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [226]
Life-threatening thyrotoxicosis or thyroid storm is a rare disorder characterized by multisystem involvement and mortality rates in the range of 8%-25% in modern series.
“Life-threatening thyrotoxicosis or thyroid storm is a rare disorder characterized by multisystem involvement and mortality rates in the range of 8%-25% in modern series (25,72,226,227).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [226]
A BWPS ≥45 appears more sensitive than a JTA classification of TS1 or TS2 in detecting patients with a clinical diagnosis of thyroid storm, but patients with a BWPS of 25-44 represent a group in whom the decision to use aggressive therapy should be based on sound clinical judgment and not based solely on diagnostic category in order to avoid overtreatment and the resultant risk of drug toxicity.
“A BWPS ‡45 appears more sensitive than a JTA classification of TS1 or TS2 in detecting patients with a clinical diagnosis of thyroid storm, but patients with a BWPS of 25-44 represent a group in whom the decision to use aggressive therapy should be based on sound clinical judgment and not based solely on diagnostic category in order to avoid overtreatment and the resultant risk of drug toxicity.”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [226]
In a recent study including 25 patients with a clinical diagnosis of thyroid storm, the BWPS was ≥45 in 20 patients and 25-44 in the remaining five, but these latter five patients (20%) were not identified using the JTA system.
“In a recent study including 25 patients with a clinical diagnosis of thyroid storm, the BWPS was ‡45 in 20 patients and 25-44 in the remaining five, but these latter five patients (20%) were not identified using the JTA system (226).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [226]
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References 26 · Cited by 147
- Authors
- Angell, T. E., Lechner, M. G., Nguyen, C. T., Salvato, V. L., Nicoloff, J. T., & LoPresti, J. S.
- Affiliations
- University of Southern California (US)
- Corresponding author
- Angell, Trevor E.
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2015-02
- Volume
- 100
- Issue
- 2
- Pages
- 451-459
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- OpenAlex
- W2123256026
- Cited by
- 147
- References
- 26
- Citations by year
- 2026: 11 · 2025: 19 · 2024: 20 · 2023: 12 · 2022: 5 · 2021: 13 · 2020: 20 · 2019: 13 · 2018: 11 · 2017: 7 · 2016: 11 · 2015: 3 · 2014: 2
- FWCI
- 6.17
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Pathology and Forensic Medicine › Ophthalmology and Eye Disorders
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Keywords
- thyroid storm, thyrotoxicosis, Burch-Wartofsky score, central nervous system disorders, altered mental status, in-hospital mortality, length of hospital stay, mechanical ventilation, thionamides, beta-adrenergic blockade, glucocorticoids, iodide therapy
- MeSH terms
- Adult, Aged, Female, Humans, Intensive Care Units, Length of Stay, Male, Middle Aged, Prognosis, Retrospective Studies, Thyroid Crisis, Hospital Mortality
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