Thyroiditis & Goitre — thyroid storm recognition and management, and the painful thyroid

Diagnosis: thyroid storm (thyrotoxic crisis) precipitated by withdrawal of antithyroid medication. The combination of severe thyrotoxicosis (suppressed TSH, high free T4) with decompensation — hyperpyrexia (40.1 degrees C), atrial fibrillation with a fast ventricular response, heart failure/pulmonary oedema, and agitation — meets the clinical criteria for thyroid storm (the Burch-Wartofsky point-score concept awards points for thermoregulatory dysfunction, CNS effects, gastrointestinal-hepatic dysfunction, tachycardia, congestive heart failure and a precipitant). The precipitant here is the missed carbimazole.^[1][2]

Immediate management — the ordered emergency bundle (ICU).^[1][2]

• Supportive — admit to ICU/HDU; oxygen and treat pulmonary oedema; IV fluids; active cooling with cooling blankets and paracetamol (avoid aspirin, which displaces thyroid hormone from binding proteins); identify and treat the precipitant.
• Block synthesis — thionamide first. Propylthiouracil (PTU) is preferred because it also blocks peripheral T4-to-T3 conversion: loading dose 500-1000 mg, then 250 mg orally/by nasogastric tube every 4 hours (carbimazole/methimazole 60-80 mg daily is an alternative but does not block conversion).
• Block release — iodine, at least 1 hour AFTER the thionamide. Giving iodine after the thionamide has blocked organification prevents the iodine from fuelling new synthesis (Jod-Basedow): Lugol's iodine 8 drops every 6 hours, or saturated solution of potassium iodide.
• Block T4-to-T3 conversion and the adrenal axis — glucocorticoids: hydrocortisone 100 mg IV every 8 hours (or dexamethasone 2 mg every 6 hours); also covers relative adrenal insufficiency.
• Block adrenergic effects — beta-blocker: propranolol 60-80 mg orally every 4-6 hours (it also blocks T4-to-T3 conversion; use IV esmolol with caution if severe heart failure). Cholestyramine may be added to block enterohepatic hormone reabsorption.

The order matters: thionamide BEFORE iodine; corticosteroid and beta-blocker given early.

Subsequent definitive plan.^[2]

• Once stable, continue carbimazole (or PTU) and plan definitive treatment of the underlying Graves disease — radioactive iodine (after a course of antithyroid drugs and after stopping them appropriately) or total thyroidectomy; lifelong levothyroxine thereafter.
• Anticoagulate for the atrial fibrillation (high thromboembolic risk in thyrotoxicosis); rate-control with the beta-blocker.
• Monitor in ICU until afebrile and haemodynamically stable; mortality remains significant despite treatment.