Snapshot A 34-year-old female with a past medical history of well-controlled Graves disease is brought to the emergency room for altered mental status. She is post-operative day 4 from an laparoscopic appendectomy for acute appendicitis. Her temperature is 104.2°F (40.1°C), blood pressure is 160/110 mmHg, pulse is 145/min, respirations are 21/min, and oxygen saturation is 95% on room air. Introduction Clinical definition life threatening condition characterized by symptoms of severe thyrotoxicosis (excessive thyroid hormone in the body) often precipitated by an acute event/trigger Associated conditions hyperthyroidism Epidemiology Risk factors longstanding, untreated hyperthyroidism surgery trauma infection parturition irregular use or discontinuation of antithyroid drugs Presentation Symptoms agitation anxiety delirium coma nausea/vomiting diarrhea abdominal pain Physical exam tachyarrythmia (can exceed 140 bpm) hypotension/hypertension hyperpyrexia jaundice Studies Diagnostic testing diagnostic approach diagnosis is clinical and based the on presence of severe and life-threatening symptoms (e.g., hyperpyrexia, cardiovascular dysfunction, and altered mentation) in a patient with biochemical evidence of hyperthyroidism (e.g., elevated free T4/T3 and low TSH) studies thyroid function tests usually not more profound than that seen in patients with uncomplicated thyrotoxicosis low TSH high free T4 and/or T3 liver function test may see abnormal liver function tests Differential Sepsis distinguishing factors rarely the extreme tachycardia seen in thyroid storm thyroid functioning tests will likely be normal in sepsis Treatment Management approach management should be immediate following clinical diagnosis and patients should be managed at the intensive care unit (ICU) due to high mortality First-line β-blocker control the symptoms and signs (e.g., tachycardia) induced by increased adrenergic tone example propranolol thionamide blocks new hormone synthesis effective within 1-2 hours post administration example propylthiouracil (PTU) or methimazole iodine solution blocks release of thyroid hormone known as the Wolff-Chaikoff effect effective within 1-2 hours post administration glucocorticoid reduces T4 to T3 conversion promotes vasomotor stability reduce autoimmune process in Graves disease treat associated relative adrenal insufficiency Long-term management in patients with Graves disease, definitive therapy with radioactive iodine or thyroidectomy may be indicated Complications Arrhythmias Decompensated heart failure Death