What is the role of the Burch-Wartofsky score in diagnosing and managing thyrotoxic crisis?

Burch-Wartofsky Score in Thyrotoxic Crisis

What the Score Is and When to Use It

The Burch-Wartofsky Point Scale (BWPS) is a clinical scoring system used to diagnose thyroid storm (thyrotoxic crisis) by quantifying the severity of symptoms across multiple organ systems, with scores ≥45 highly suggestive of thyroid storm, 25-44 indicating impending storm, and <25 making the diagnosis unlikely. 1

• The BWPS has been the standard empirically-derived diagnostic tool since the early 1990s for identifying this life-threatening endocrine emergency 1
• This scoring system is critical because thyroid storm carries approximately 90% mortality if undiagnosed and untreated 2

Components Evaluated by the Score

The BWPS systematically assesses:

• Thermoregulatory dysfunction: Fever severity (higher temperatures score more points) 1
• Cardiovascular manifestations: Tachycardia, arrhythmias (including supraventricular tachycardia), and heart failure 2, 1
• Central nervous system involvement: Ranging from agitation to psychosis, severe lethargy, or coma 2, 3
• Gastrointestinal-hepatic dysfunction: Diarrhea, nausea/vomiting, abdominal pain 4, 3
• Precipitating factors: Infection, recent iodine exposure, medication non-compliance, or other stressors 4, 1

Clinical Presentation Requiring Score Assessment

Evaluate any patient with known or suspected hyperthyroidism presenting with:

• Fever with tachycardia disproportionate to the degree of fever 2
• Altered mental status, confusion, agitation, or coma in the context of thyrotoxicosis 5, 3
• Cardiac decompensation: SVT, atrial fibrillation, or heart failure symptoms 2, 1
• Severe neurological deficits that may be monosymptomatic, especially in elderly patients 5

Score Interpretation and Management Algorithm

Score ≥45 (Thyroid Storm Highly Likely):

• Immediate aggressive multi-modal treatment required 1
• Antithyroid drugs (propylthiouracil preferred over methimazole in crisis) 4
• Potassium iodide (given at least 1 hour after antithyroid drugs) 4
• Beta-blockers (propranolol or atenolol) for cardiovascular symptoms 6, 4
• Corticosteroids to block peripheral T4 to T3 conversion 4
• Involve experienced endocrinologist immediately 2
• Consider emergency thyroidectomy if medical management fails or agranulocytosis develops 5, 4

Score 25-44 (Impending Storm):

• Initiate treatment as above but with close monitoring for progression 1
• Endocrine consultation mandatory 2
• Hospitalization required 6

Score <25 (Storm Unlikely):

• Manage as severe thyrotoxicosis with beta-blockers and supportive care 6
• Monitor closely for deterioration 6

Critical Pitfalls to Avoid

• Do not wait for laboratory confirmation of thyroid hormone levels before treating - thyroid storm is a clinical diagnosis and treatment must begin immediately based on BWPS score 2
• Recognize atypical presentations: Elderly patients may present with predominantly neurological symptoms (headache, psychosis, coma) without classic hyperthyroid features 5
• Never give iodine before antithyroid drugs - this can worsen thyrotoxicosis by providing substrate for more hormone synthesis 4
• Do not overlook precipitating factors: Recent COVID-19 infection, medication non-compliance, iodine exposure, or underlying infection can trigger crisis 4, 1
• Emergency surgery may be necessary even without achieving euthyroidism first if medical management fails, particularly in elderly patients with severe neurological involvement 5

Special Considerations

• Agranulocytosis risk: If propylthiouracil causes agranulocytosis during treatment, emergency thyroidectomy becomes the definitive treatment option 4
• Recovery timeline: With appropriate treatment including surgery when indicated, euthyroidism can be achieved within 2 days and neurological symptoms resolve within 4 days on average 5
• Complete recovery is possible even in severe cases with coma if thyroid storm is recognized early and treated aggressively 5, 4