Re: Intravenous beta-blockade in the pulmonary oedema of thyroid storm
We are not sure why Daly et al wish to describe the present case or
their own as examples of ‘thyroid storm’. The diagnostic criteria
suggested by Burch and Wartofsky (1) and reprised by Ross (2) were based
on 61 published cases of thyroid storm and therefore had a sensitivity
approaching 100%. The specificity and utility of the index remain
untested. We suspect that the specificity of the index may be nearer 50%
and therefore a doubtful guide to diagnosis and management. We prefer to
keep the epithet for the combination of severe hyperthyroidism with fever,
tachycardia and confusion without an alternative explanation. The term is
also used to describe the hypermetabolic state associated with fever and
tachycardia in hyperthyroid patients during anaesthesia. Whatever the
semantics the practical treatment issues are the same in any given case of
severe hyperthyroidism (3).
In our patient with severe hyperthyroidism, pneumonia and
decompensated low output heart failure, beta-blockers including the short-
acting esmolol are better avoided for reasons already outlined both in the
paper and subsequent online discussion.
We agree with the recommendation to use a cocktail of antithyroid
drug treatment to lower the circulating hormones as quickly as possible,
as initially described (4).
References
1 Burch HB, and Wartofsky L. Life-threatening thyrotoxicosis.
Thyroid storm. Endocrinol Metab Clin N America 1993; 22 (2): 263-77.
2 Ross DS. Thyroid storm. In: UpToDate, Basow, DS. (Ed) 2009;
UpToDate, Waltham, MA
3 Davies TF, and Larsen PR. Thyroid storm. In Chapter 11.
Thyrotoxicosis. Williams Textbook of Endocrinology. Ed Kronenberg HM,
Melmed S, Polonsky KS, Larsen PR. (Saunders), 11th Edition. 2009, 357-8.
4 Croxson MS, Hall TD, Nicoloff JT. Combination drug therapy for
treatment of hyperthyroid Graves’ disease. Journal of Clinical
Endocrinology & Metabolism 1977; 45 (4): 623-30
Rapid Response:
Re: Intravenous beta-blockade in the pulmonary oedema of thyroid storm
We are not sure why Daly et al wish to describe the present case or
their own as examples of ‘thyroid storm’. The diagnostic criteria
suggested by Burch and Wartofsky (1) and reprised by Ross (2) were based
on 61 published cases of thyroid storm and therefore had a sensitivity
approaching 100%. The specificity and utility of the index remain
untested. We suspect that the specificity of the index may be nearer 50%
and therefore a doubtful guide to diagnosis and management. We prefer to
keep the epithet for the combination of severe hyperthyroidism with fever,
tachycardia and confusion without an alternative explanation. The term is
also used to describe the hypermetabolic state associated with fever and
tachycardia in hyperthyroid patients during anaesthesia. Whatever the
semantics the practical treatment issues are the same in any given case of
severe hyperthyroidism (3).
In our patient with severe hyperthyroidism, pneumonia and
decompensated low output heart failure, beta-blockers including the short-
acting esmolol are better avoided for reasons already outlined both in the
paper and subsequent online discussion.
We agree with the recommendation to use a cocktail of antithyroid
drug treatment to lower the circulating hormones as quickly as possible,
as initially described (4).
References
1 Burch HB, and Wartofsky L. Life-threatening thyrotoxicosis.
Thyroid storm. Endocrinol Metab Clin N America 1993; 22 (2): 263-77.
2 Ross DS. Thyroid storm. In: UpToDate, Basow, DS. (Ed) 2009;
UpToDate, Waltham, MA
3 Davies TF, and Larsen PR. Thyroid storm. In Chapter 11.
Thyrotoxicosis. Williams Textbook of Endocrinology. Ed Kronenberg HM,
Melmed S, Polonsky KS, Larsen PR. (Saunders), 11th Edition. 2009, 357-8.
4 Croxson MS, Hall TD, Nicoloff JT. Combination drug therapy for
treatment of hyperthyroid Graves’ disease. Journal of Clinical
Endocrinology & Metabolism 1977; 45 (4): 623-30
Competing interests:
None declared
Competing interests: No competing interests