Neurological Manifestations Predict Mortality in Thyroid Storm

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: MON 437-470-Non-neoplastic Thyroid Disorders
Monday, June 17, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board MON-451
Du Soon Swee*, Chiaw Ling Chng and Adoree Yi Ying Lim
Singapore General Hospital, Singapore, Singapore
INTRODUCTION: Thyroid storm is an extreme manifestation of thyrotoxicosis which is associated with multiorgan failure and high mortality risk. Due to its rarity, little is known about the spectrum of clinical manifestations and high risk features that may predict worse outcomes.

OBJECTIVE: This retrospective study aims to describe the clinical and epidemiological features of patients with thyroid storm admitted to a tertiary institution in Singapore, and to identify specific determinants that predict mortality.

METHOD: Subjects admitted to Singapore General Hospital with thyroid storm between 2006 and 2011 were included. Both electronic and written medical records were reviewed, and Burch Wartofsky (BW) scoring system for thyroid storm was applied in each case. Data entry and statistical analyses were performed with SPSS Software for Windows Statistics version 17.0.

RESULTS: Twenty eight patients were admitted over the specified 5 year period for thyroid storm. Ages ranged from 24 to 75 years old, with a mean of 47.5 years. There was a slight male preponderance, with a male to female ratio of 1.33:1. Fifteen (53.6%) had past history of hyperthyroidism, and 12 of them were found to be non-compliant with treatment. Twelve patients (42.9%) required invasive ventilatory support. Etiologies of thyrotoxicosis include 25 cases of Graves’ disease (TSH receptor antibody positivity) and 1 case of hyperfunctioning papillary thyroid carcinoma. Mortality rate was 25%. Majority presented with cardiac manifestations (severe tachycardia: 60.7%, atrial fibrillation: 67.8%). Mild to moderate degree of central nervous system (CNS) derangements were present in 28.5% (8 subjects), and none demonstrated severe CNS signs (seizure, coma).

Moderate CNS involvement (delirium, psychosis, extreme lethargy) was found to have statistically significant correlation with mortality (P = 0.008) on bivariate analysis. Total BW score, age, free thyroid (T4) hormone level and other systemic involvement (thermoregulatory, cardiovascular, gastrointestinal-hepatic) were not found to be predictive of mortality.

CONCLUSION: Thyroid storm is a life threatening condition with a mortality rate of 25% in this study. Patients who presented with neurological manifestations had significantly greater risk of mortality. While further research is required to elucidate the underlying mechanism of CNS dysfunction in thyroid storm, presence of this red flag demands timely and aggressive treatment measures.

(1) Bindu Nayak et al. Thyrotoxicosis and Thyroid Storm. Endocrinol Metab Clin N Am 35 (2006) 663-686 (2) Su Yin Adeline Ngo et al. When the storm passes unnoticed - A case series of thyroid storm. Resuscitation (2007) 73, 485-490

Nothing to Disclose: DSS, CLC, AYYL

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