Thyroid Emergencies in Critically Ill Cancer Patients

  • Sarimar Agosto
  • Sonali ThosaniEmail author
Reference work entry


Thyroid emergencies are uncommon. However, given the systemic effects of thyroid hormone, dysfunction from severe hypothyroidism or severe thyrotoxicosis requires prompt diagnosis and management on intensive care unit. Both myxedema coma and thyroid storm are clinical diagnoses in which lack of timely therapy can result in fatal consequences. History and physical exam are cornerstones to establishing diagnosis with low threshold to suspect infection as a potential trigger event especially in the immunosuppressed cancer patient. In addition to close observation of cardiorespiratory status, antithyroid drugs for thyroid storm and levothyroxine treatment for myxedema coma, both emergent scenarios require empirical coverage with glucocorticoids until adrenal insufficiency is ruled out. Careful review of medications is important as newer chemotherapeutic agents like tyrosine kinase inhibitors and immune checkpoint inhibitors are known to cause thyroid dysfunction. There are many challenges in interpreting thyroid function tests in the setting of acute illness as patients can present with transient test abnormalities denominated as euthyroid sick syndrome or non-thyroidal illness syndrome (NTIS), which is a physiologic adaptation of the hypothalamic-pituitary-thyroid axis.


Thyroid storm Thyrotoxic crisis Hyperthyroidism Non-thyroidal illness Myxedema coma Hypothyroidism Euthyroid sick syndrome Thyroid emergencies 


  1. 1.
    Akamizu T. Thyroid storm: a Japanese perspective. Thyroid. 2018;28(1):32–40. Scholar
  2. 2.
    Akamizu T, Satoh T, Isozaki O, Suzuki,A, Wakino S, Iburi T, … Japan Thyroid A. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys.[Erratum appears in Thyroid. 2012;22(9):979]. Thyroid. 2012;22(7):661–679.
  3. 3.
    Alfadhli E, Gianoukakis AG. Management of severe thyrotoxicosis when the gastrointestinal tract is compromised. Thyroid. 2011;21(3):215–20. Scholar
  4. 4.
    Alswat KA. Role of cholestyramine in refractory hyperthyroidism: a case report and literature review. Am J Case Rep. 2015;16:486–90. Scholar
  5. 5.
    Arlot S, Debussche X, Lalau JD, Mesmacque A, Tolani M, Quichaud J, Fournier A. Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care Med. 1991;17(1):16–8.CrossRefGoogle Scholar
  6. 6.
    Barroso-Sousa R, Barry WT, Garrido-Castro AC, et al. Incidence of endocrine dysfunction following the use of different immune checkpoint inhibitor regimens: a systematic review and meta-analysis. JAMA Oncol. 2018;4(2):173–82. Scholar
  7. 7.
    Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metabol Clin North Am. 1993;22(2):263–77.CrossRefGoogle Scholar
  8. 8.
    Carhill A, Gutierrez A, Lakhia R, Nalini R. Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis. BMJ Case Rep. 2012;
  9. 9.
    Chakraborty S, Fedderson J, Gums JJ, Toole A. Amiodarone-induced myxedema coma – a case and review of the literature. Arch Med Sci. 2014;10(6): 1263–7. Scholar
  10. 10.
    Chaudhari D, Gangadharan V, Forrest T. Heart failure presenting as myxedema coma: case report and review article. [Republished in Tenn Med. 2014; 107(2):39–41; PMID: 24592692]. Tenn Med. 2013; 106(5):39–40.PubMedGoogle Scholar
  11. 11.
    Chen SY, Kao PC, Lin ZZ, Chiang WC, Fang CC. Sunitinib-induced myxedema coma. Am J Emerg Med. 2009;27(3):370.e371–3. Scholar
  12. 12.
    Chen T-S, Wen M-J, Hung Y-J, Hsieh C-H, Hsiao F-C. A rare storm in a psychiatric ward: thyroid storm. Gen Hosp Psychiatry. 2012;34(2):210.e211–4. Scholar
  13. 13.
    Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. J Intensive Care Med. 2015;30(3):131–40. Scholar
  14. 14.
    Chopra IJ. Euthyroid sick syndrome: is it a misnomer? J Clin Endocrinol Metabol. 1997;82(2):329–34. Scholar
  15. 15.
    Cooper DS. Antithyroid drugs. N Engl J Med. 1984;311(21):1353–62. Scholar
  16. 16.
    de Vries EM, Fliers E, Boelen A. The molecular basis of the non-thyroidal illness syndrome. J Endocrinol. 2015;225(3):R67–81. Scholar
  17. 17.
    Eliades M, El-Maouche D, Choudhary C, Zinsmeister B, Burman KD. Takotsubo cardiomyopathy associated with thyrotoxicosis: a case report and review of the literature. Thyroid. 2014;24(2):383–9. Scholar
  18. 18.
    Fliers E, Bianco AC, Langouche L, Boelen A. Thyroid function in critically ill patients. Lancet Diabetes Endocrinol. 2015;3(10):816–25. Scholar
  19. 19.
    Fliers E, Wiersinga WM. Myxedema coma. Rev Endocr Metab Disord. 2003;4(2):137–41.CrossRefGoogle Scholar
  20. 20.
    Grais IM, Sowers JR. Thyroid and the heart. Am J Med. 2014;127(8):691–8. Scholar
  21. 21.
    Hampton J. Thyroid gland disorder emergencies: thyroid storm and myxedema coma. AACN Adv Crit Care. 2013;24(3):325–32. Scholar
  22. 22.
    Hatch DM, Roy RC. Cancer and deliberate hypothyroidism, anesthesia, and myxedema coma: the curse of oncologic outcomes based on hypothyroidism. J Clin Anesth. 2013;25(1):1–3. Scholar
  23. 23.
    Idrose AM. Acute and emergency care for thyrotoxicosis and thyroid storm. Acute Med Surg. 2015;2(3):147–57. Scholar
  24. 24.
    Jha S, Waghdhare S, Reddi R, Bhattacharya P. Thyroid storm due to inappropriate administration of a compounded thyroid hormone preparation successfully treated with plasmapheresis. Thyroid. 2012;22(12):1283–6. Scholar
  25. 25.
    Jongjaroenprasert W, Akarawut W, Chantasart D, Chailurkit L, Rajatanavin R. Rectal administration of propylthiouracil in hyperthyroid patients: comparison of suspension enema and suppository form. Thyroid. 2002;12(7):627–31. Scholar
  26. 26.
    Kaykhaei MA, Shams M, Sadegholvad A, Dabbaghmanesh MH, Omrani GR. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine. 2008;34(1):52–5. Scholar
  27. 27.
    Klein I, Danzi S. Thyroid disease and the heart. Curr Probl Cardiol. 2016;41(2):65–92. Scholar
  28. 28.
    Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin N Am. 2012;96(2):385–403. Scholar
  29. 29.
    Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007;22(4):224–31.CrossRefGoogle Scholar
  30. 30.
    Lin YQ, Wang X, Murthy MS, Agarwala S. Life-threatening thyrotoxicosis induced by combination therapy with peg-interferon and ribavirin in chronic hepatitis c. Endocr Pract. 2005;11(2):135–9. Scholar
  31. 31.
    Mancano MA. Sorafenib-induced thyroid storm; ceftaroline-induced eosinophilic pneumonia; imatinib-induced osteonecrosis of the tibia; visual and auditory hallucinations with citalopram. Hosp Pharm. 2014;49(2):121–6. Scholar
  32. 32.
    Martinez-Diaz GJ, Formaker C, Hsia R. Atrial fibrillation from thyroid storm. J Emerg Med. 2012;42(1):e7–9. Scholar
  33. 33.
    Mathes DD. Treatment of myxedema coma for emergency surgery. Anesth Analg. 1998;86(2):450–1.PubMedGoogle Scholar
  34. 34.
    Mathew V, Misgar RA, Ghosh S, Mukhopadhyay P, Roychowdhury P, Pandit K, … Chowdhury S. Myxedema coma: a new look into an old crisis. J Thyroid Res. 2011;2011:493462.
  35. 35.
    Mavroson MM, Patel N, Akker E. Myxedema psychosis in a patient with undiagnosed Hashimoto thyroiditis. J Am Osteopath Assoc. 2017;117(1): 50–4. Scholar
  36. 36.
    McMillen B, Dhillon MS, Yong-Yow S. A rare case of thyroid storm. BMJ Case Rep. 2016;
  37. 37.
    Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metabol Clin North Am. 2006;35(4):663–86, viiCrossRefGoogle Scholar
  38. 38.
    Ngo AS-Y, Lung Tan DC. Thyrotoxic heart disease. Resuscitation. 2006;70(2):287–90. Scholar
  39. 39.
    Noh KW, Seon CS, Choi JW, Cho YB, Park JY, Kim HJ. Thyroid storm and reversible thyrotoxic cardiomyopathy after ingestion of seafood stew thought to contain marine neurotoxin. Thyroid. 2011;21(6): 679–82. Scholar
  40. 40.
    Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: analysis of a national inpatient database in Japan. J Epidemiol. 2017;27(3):117–22. Scholar
  41. 41.
    Papi G, Corsello SM, Pontecorvi A. Clinical concepts on thyroid emergencies. Front Endocrinol. 2014;5:102. Scholar
  42. 42.
    Popoveniuc G, Chandra T, Sud A, Sharma M, Blackman MR, Burman KD, … Wartofsky L. A diagnostic scoring system for myxedema coma. Endocr Pract, 2014;20(8):808–817.
  43. 43.
    Rodriguez I, Fluiters E, Perez-Mendez LF, Luna R, Paramo C, Garcia-Mayor RV. Factors associated with mortality of patients with myxoedema coma: prospective study in 11 cases treated in a single institution. J Endocrinol. 2004;180(2):347–50.CrossRefGoogle Scholar
  44. 44.
    Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, … Walter MA. 2016 American thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343–1421.
  45. 45.
    Sahoo JP, Selviambigapathy J, Kamalanathan S, Nagarajan K, Vivekanandan M. Effect of steroid replacement on thyroid function and thyroid autoimmunity in Addison’s disease with primary hypothyroidism. Ind J Endocrinol Metabol. 2016;20(2): 162–6. Scholar
  46. 46.
    Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, … Akamizu T. 2016 guidelines for the management of thyroid storm from the Japan Thyroid association and Japan Endocrine Society (first edition). Endocr J. 2016;63(12):1025–1064.
  47. 47.
    Shaked Y, Samra Y, Zwas ST. Graves’ disease presenting as pyrexia of unknown origin. Postgrad Med J. 1988;64(749):209–12.CrossRefGoogle Scholar
  48. 48.
    Spittle L. Diagnoses in opposition: thyroid storm and myxedema coma. AACN Clin Issues Crit Care Nurs. 1992;3(2):300–8.CrossRefGoogle Scholar
  49. 49.
    Tietgens ST, Leinung MC. Thyroid storm. Med Clin N Am. 1995;79(1):169–84.CrossRefGoogle Scholar
  50. 50.
    Tokushima Y, Sakanishi Y, Nagae K, Tokushima M, Tago M, Tomonaga M, … Yamashita S-I. Thyroid storm complicated by Bicytopenia and disseminated intravascular coagulation. Am J Case Rep. 2014;15:312–316.
  51. 51.
    Tsai WC, Pei D, Wang TF, Wu DA, Li JC, Wei CL, … Kuo SW. The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves’ hyperthyroidism. Clin Endocrinol. 2005;62(5):521–524.
  52. 52.
    Umezu T, Ashitani K, Toda T, Yanagawa T. A patient who experienced thyroid storm complicated by rhabdomyolysis, deep vein thrombosis, and a silent pulmonary embolism: a case report. BMC Res Notes. 2013;6:198. Scholar
  53. 53.
    Van den Berghe G. Non-thyroidal illness in the ICU: a syndrome with different faces. Thyroid. 2014;24(10): 1456–65. Scholar
  54. 54.
    Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. 2000;62(11):2485–90.PubMedGoogle Scholar
  55. 55.
    Walter RM, Bartle WR. Rectal administration of propylthiouracil in the treatment of graves’ disease. Am J Med. 1990;88(1):69–70. Scholar
  56. 56.
    Warner MH, Beckett GJ. Mechanisms behind the non-thyroidal illness syndrome: an update. J Endocrinol. 2010;205(1):1–13. Scholar
  57. 57.
    Wartofsky L. Myxedema coma. Endocrinol Metabol Cli North Am. 2006;35(4):687–98, vii–viiiCrossRefGoogle Scholar
  58. 58.
    Wartofsky L. Clinical criteria for the diagnosis of Thyroid storm. Thyroid. 2012;22(7):659–60. Scholar
  59. 59.
    Wiersinga WM, Duntas L, Fadeyev V, Nygaard B, Vanderpump MP. 2012 ETA guidelines: the use of L-T4 + L-T3 in the treatment of hypothyroidism. Eur Thyroid J. 2012;1(2):55–71. Scholar
  60. 60.
    Wilson BE, Hobbs WN. Case report: pseudoephedrine-associated thyroid storm: thyroid hormone-catecholamine interactions. Am J Med Sci. 1993;306(5):317–9.CrossRefGoogle Scholar
  61. 61.
    Yamamoto T, Fukuyama J, Fujiyoshi A. Factors associated with mortality of myxedema coma: report of eight cases and literature survey. Thyroid. 1999;9(12):1167–74.CrossRefGoogle Scholar
  62. 62.
    Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid. 1995;5(5): 403–5. Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of EndocrinologyUniversity Health System and University of Texas Health San AntonioSan AntonioUSA
  2. 2.Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA

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