What are the symptoms of thyroid storm in a patient with hyperthyroidism undergoing thyroidectomy?

Symptoms of Thyroid Storm in Patients Undergoing Thyroidectomy

Thyroid storm presents with fever and tachycardia out of proportion to the fever, altered mental status, gastrointestinal symptoms beyond typical surgical recovery, and cardiac complications—this is a clinical diagnosis that requires immediate treatment without waiting for laboratory confirmation. 1, 2

Cardinal Clinical Features

Cardiovascular Manifestations

• Tachycardia disproportionate to fever is the hallmark cardiovascular sign, often exceeding 140 beats per minute 2, 3
• Cardiac arrhythmias, particularly atrial fibrillation, occur frequently and may require urgent management 1, 2, 4
• Signs of congestive heart failure including respiratory distress and pulmonary edema 2, 4
• Labile or elevated blood pressure may be present 5

Thermoregulatory Dysfunction

• Hyperthermia (often >39°C or 102°F) that is excessive relative to the clinical situation 2, 6, 3
• Fever that does not respond adequately to standard antipyretics 3

Neuropsychiatric Symptoms

• Altered mental status ranging from nervousness and agitation to confusion, delirium, seizures, or coma 1, 2, 6
• Restlessness and extreme anxiety that progresses rapidly 2, 5
• Postoperative agitation lasting hours beyond expected emergence from anesthesia 3

Gastrointestinal Manifestations

• Vomiting and diarrhea that exceed typical postoperative nausea 2, 6
• Generalized abdominal pain 4
• Hepatic dysfunction with potential progression to fulminant hepatic failure in severe cases 6, 4

Respiratory Complications

• Respiratory distress and tachypnea 6
• Hypercapnic respiratory failure requiring mechanical ventilation in severe presentations 5

Critical Diagnostic Considerations

Clinical Diagnosis Takes Priority

• Treatment must begin immediately based on clinical suspicion alone—never delay for laboratory confirmation, as mortality rises significantly with treatment delays 1, 2
• The diagnosis is primarily clinical, though thyroid function tests showing elevated free T4 and suppressed TSH support the diagnosis 6, 5

Perioperative Context

• Thyroid storm can occur intraoperatively (during the procedure itself) or in the immediate postoperative period 7, 3
• The incidence ranges from 0% to 14% in various surgical series, with all treatment groups showing some risk 7
• Surgery itself serves as a major precipitating factor, particularly in patients with inadequately controlled hyperthyroidism 6, 7, 5

Common Pitfalls to Avoid

• Do not attribute tachycardia and fever solely to surgical stress or infection—thyroid storm must be in the differential for any hyperthyroid patient with these symptoms perioperatively 3, 5
• Do not wait for thyroid function test results before initiating treatment, as clinical diagnosis is sufficient and delays increase mortality 1, 2
• Recognize that even patients who have undergone total thyroidectomy can develop thyroid storm if they have metastatic thyroid tissue or incomplete thyroid removal 6
• Be aware that symptoms may develop days after surgery or after exposure to iodinated contrast (14-35 million mcg vs. 150 mcg daily requirement) 6

Multiorgan Decompensation Pattern

• Thyroid storm represents multiorgan system failure rather than isolated hyperthyroid symptoms 6
• Cardiac, hepatic, neurologic, and gastrointestinal systems all show simultaneous dysfunction 6, 4
• Mortality can reach 30% or higher when complications like fulminant hepatic failure or severe heart failure develop 4