Thyroid Storm: A Japanese Perspective

Abstract

Background: Thyroid storm (TS) is life threatening. In the mid-2000s, its incidence was poorly defined, peer-reviewed diagnostic criteria were not available, and management and treatment did not seem to be verified based upon evidence and latest advances in medicine.

Methods: First, diagnostic criteria were developed based on 99 patients in the literature and seven patients in this study. Then, initial and follow-up surveys were conducted from 2004 through 2008, targeting all hospitals in Japan to obtain and verify information on patients who met diagnostic criteria for TS. Based on these data, the diagnostic criteria were revised, and management and treatment guidelines were created.

Results: The incidence of TS in hospitalized patients in Japan was estimated to be 0.20 per 100,000 per year and 0.22% of all thyrotoxic patients. The mortality rate was 10.7%. Multiple organ failure was the most common cause of death, followed by congestive heart failure, respiratory failure, and arrhythmia. In the final diagnostic criteria for TS, the definition of jaundice as serum bilirubin concentration >3 mg/dL was added. Based upon nationwide surveys and the latest information, guidelines for the management and treatment for TS were extensively revised and algorithms were developed.

Conclusions: TS remains a life-threatening disorder, with >10% mortality in Japan. New peer-reviewed diagnostic criteria for TS are presented and its clinical features, prognosis, and incidence are clarified based on nationwide surveys. Furthermore, this information helped to establish detailed guidelines for the management and treatment of TS. A prospective prognostic study to validate the guidelines is eagerly anticipated.

Keywords: diagnostic criteria; guideline; management; thyroid crisis; treatment.

FIG. 1.

Changes in the number of patients with thyroid storm (TS) managed by endocrinology and emergency departments. *Creation of Japanese task force for TS; **initial dissemination of tentative diagnostic criteria for TS.

FIG. 2.

Causes of death in Japanese patients with TS. CHF, congestive heart failure; DIC, disseminated intravascular coagulation; GI, gastrointestinal; MOF, multiple organ failure.

FIG. 3.

Combinations of clinical features in Japanese patients with TS. (A) Patients with CNS features (n = 238); (B) patients without CNS features (n = 44). CNS, central nervous system; bpm, beats per minute.

FIG. 4.

Relationship between scores based on Burch–Wartofsky Point Scale (BWPS) and diagnosis based on criteria for TS from the Japan Thyroid Association (JTA) (10). Tox-NoTS, thyrotoxicosis without TS. ○, definite cases; ▴, suspected cases; × , Tox-NoTS. Curved lines indicate the probabilities of JTA criteria by BWPS based on logistic regression analysis (black solid line, definite cases; blue solid line, suspected cases; black dotted line, Tox-NoTS).