Anaesthesia, 2004, 59, pages 1020–1022

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CASE REPORT
Thyroid storm prior to induction of anaesthesia
E. A. Hirvonen,1 L. K. Niskanen,2 and M. M. Niskanen3
1 Deputy Chief Physician, Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Finland
2 Professor, Department of Medicine, Kuopio University Hospital, Finland
3 Deputy Chief Physician, Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Finland

Summary
A 53- year-old woman without a previous history of thyroid disease was scheduled for mastectomy.
On arrival in the operating theatre unpremedicated she appeared restless and tachycardic. Mida-
zolam and fentanyl was administered intravenously. Concomitantly, sinus tachycardia developed
and a flush reaction was observed in the skin of the thoracic region and neck. The blood pressure
increased to 265 ⁄ 160 mmHg and the patient lost consciousness and became apnoeic. Uncon-
sciousness and apnoea lasted for approximately 25 min and the operation was postponed. Further
investigations revealed an elevated serum free thyroxine level and suppressed serum thyrotropin
diagnostic of hyperthyroidism. The serum TSH receptor antibody concentration was elevated,
indicating that the patient was suffering from Graves’ disease. We present a case of a previously
unknown hyperthyroid patient, with breast cancer, presenting as a thyroid crisis on induction of
anaesthesia. Although being quite a rare occurrence, unsuspected thyroid disease should be borne
in mind when an agitated patient enters the operating theatre.

Keywords Intraoperative complications: hypertension. Thyroid storm.

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Correspondence to: Eila Hirvonen
E-mail: eila.hirvonen@kuh.fi
Accepted: 31 March 2004

The occurrence of thyroid storm is an infrequent

Case report
manifestation of hyperthyroidism due to the widespread
use of thyroid function tests, which enable the diagnosis A 53-year-old woman (ASA physical status II, 153 cm,
of the disease even in its subclinical form. However, 53 kg) was scheduled for a right mastectomy. Previous
thyroid storm can develop very rapidly and bears little history revealed that she suffered from migraine and was
relationship to circulating thyroid hormone levels [1]. allergic to acetylsalicylic acid, rubber, iodine and nickel.
Surgical operations are one of the commonly cited She had previously undergone left mastectomy for
precipitating factors for a thyroid crisis [1–4]. The malignancy, six years earlier. At that time anaesthesia
majority of these case reports date from earlier decades and surgery were uneventful. She was otherwise fit and
and nearly all have occurred in the postoperative period. had not undergone any other surgery and received no
Only one previous report can be found where a patient regular medication. She was a Jehovah’s Witness and
developed thyroid storm on induction of anaesthesia [3]. stated that she would not accept any blood transfusions.
The clinical symptoms and signs of thyroid storm can Her initial blood pressure on the surgical ward on the day
mimic several other conditions, for example malignant prior to surgery was 207 ⁄ 101 mmHg, but this decreased
hyperthermia, phaeochromocytoma, hypertensive crisis, to 157 ⁄ 86 mmHg. Her ECG showed signs of left
anaphylactic reaction, and neuroleptic malignant syn- ventricular hypertrophy and chest radiograph revealed a
drome. It is challenging to distinguish between these dilated heart.
conditions. We describe a case of thyrotoxic storm She was prescribed 10 mg of diazepam as pre-
presenting during the induction of anaesthesia. medication; however, the operation schedule was

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Anaesthesia, 2004, 59, pages 1020–1022 E. A. Hirvonen et al. Æ Thyroid storm prior to induction of anaesthesia
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unexpectedly changed and she arrived in the operating the beta-blocker propranolol. The serum TSH receptor
theatre unpremedicated. She was agitated and tachycar- antibody concentration was 28 U.l)1 (normal range <
dic (heart rate, 100–120 beats.min)1) but had no notable 9 U.l)1) suggesting that the patient had Graves’ disease.
tremor. Her blood pressure was 205 ⁄ 105 mmHg. A On further examination she recalled mild eye symptoms
peripheral venous catheter was placed in her forearm and and on palpation thyroid gland appeared somewhat
a total of 3 mg of midazolam and 0.1 mg fentanyl was enlarged and of firm consistency. She was subsequently
administered over 10 min for sedation and control of treated with long-term antithyroid medication. Four
heart rate. However, a sinus tachycardia increased to weeks after starting the antithyroid medication, the
150 beats.min)1 and a flush reaction was observed in the patient was considered stable enough for the breast
skin of the upper thoracic region. The possibility of surgery, but at her own request the operation was
anaphylactic reaction was considered, but before epi- postponed for two months, this was performed unevent-
nephrine administration the blood pressure increased fully at this time.
rapidly up to 265 ⁄ 160 mmHg. Simultaneously, the
patient lost consciousness and became apnoeic. She was
Discussion
easily ventilated with 100% oxygen using a face mask.
Her oxygen saturation remained normal and end-tidal Thyroid storm or crisis is a life–threatening syndrome.
carbon dioxide concentrations were also within normal Although its incidence is not known, it is much less
limits. On physical examination, the patient did not common today than previously due to earlier diagnosis of
respond to commands or to pain, her skin was warm and thyrotoxicosis [1]. Our patient had only minor symptoms
there was no muscle rigidity. An iv bolus of 250 mg prior to the development of the thyroid storm. Even
hydrocortisone and 15 mg labetalol was administered. A afterwards she recalled only unusual nervousness, sweat-
radial artery cannula was inserted for continuous blood ing, minor tremor, and hardly noticeable eye symptoms
pressure measurement. Arrangements were made to for some weeks before the scheduled operation. This may
perform a CT examination of her head. However, 20– be due to the fact that thyroid storm develops in most
25 min following the loss of consciousness, the patient instances rapidly, and curiously, the serum free thyroid
recovered. She began to respond to commands and her hormone concentrations are not appreciably greater than
neurological status returned to normal and her blood those seen in uncomplicated thyrotoxicosis [1]. However,
pressure and heart rate returned towards normal. The it is likely that the concentrations of thyroid hormones
operation was postponed and the patient was transferred could have increased transiently prior to the onset of the
to the recovery room. She was normotensive and thyroid crisis [5].
normothermic, but restless, sweaty and tachycardic. The presentation of thyroid storm includes fever and
Electrocardiography showed no acute changes. Addi- tachycardia, with infection commonly being a precipita-
tional investigations were arranged including, cardiac ting factor. Profuse sweating with high fever out of
enzymes, urine catecholamine metabolites and thyroid proportion to the infection may be a clue to the presence
hormone tests as well as echocardiography and an of thyroid storm [1]. Signs of encephalopathy, anxiety,
abdominal CT scan. The working diagnosis was a emotional lability, restlessness, agitation, confusion, delir-
hypertensive crisis caused by previously undiagnosed ium, frank psychosis, and coma are commonly present.
hypertension. The patient was transferred to the coron- Cardiac manifestations are frequent ranging from sinus
ary care unit, and medication with a beta-blocker tachycardia and atrial arrhytmias to congestive heart
(metoprolol) and calcium-channel blocking agents failure. Systolic hypertension and widened pulse pressure
(amlodipine) and benzodiazepine (oxazepam) were is a common occurrence, but vascular collapse may be
commenced. a later consequence. Gastrointestinal manifestations
In spite of the antihypertensive medication, the patient may mimic those of an acute abdomen or intestinal
continued to be hypertensive and agitated. Echocardio- obstruction. Diffuse abdominal pain and hepato- and
graphy of the heart showed hyperkinetic circulation but splenomegaly can occur and liver enzymes are frequently
no signs of chronic hypertensive heart disease. Abdominal abnormal [1].
CT scan showed normal adrenal glands. Three days later, Many conditions can provoke a thyrotoxic crisis, such
the thyroid hormone tests showed that the free thyrox- as infection, trauma, surgical emergencies, operations,
ine concentration was 79.5 pmol.l)1 (normal range 8– toxaemia of pregnancy, diabetic ketoacidosis or partur-
20 pmol.l)1) and the thyroid-stimulating hormone (TSH) ition [1]. In our patient, the main reason for thyroid storm
concentration was 0.02 mU.l)1 (normal range 0.04– may have been acute emotional stress. The patient was
5 mU.l)1). The patient’s symptoms were alleviated soon unpremedicated which would have increased anxiety
after starting antithyroid medication with carbimazole and levels as would peripheral venous cannulation. However

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E. A. Hirvonen et al. Æ Thyroid storm prior to induction of anaesthesia Anaesthesia, 2004, 59, pages 1020–1022
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the unintended omission of premedication may actually decrease the production of thyroid hormones. Second,
have been a fortunate event as otherwise her symptoms the systemic manifestations of fever and hypovolaemia
may have been masked by premedication and we might should be treated. Third, the tachycardia and tremor
have proceeded to general anaesthesia and observed should be treated using beta-blockers and finally, the
marked circulatory instability during operation. Previ- precipitating illness should be treated [1].
ously, one report of a patient who developed thyroid In conclusion, thyroid storm can be precipitated by
storm during the induction of anaesthesia has been anaesthesia and surgery and the clinical symptoms and
published [3]. This case was mistakenly diagnosed as signs can mimic those of several other conditions. Once
malignant hyperthermia and was treated accordingly with the diagnosis is made however, the treatment should be
dantrolene. Pugh and coworkers [6] have described a case relatively straightforward.
of an undiagnosed thyrotoxic patient who was anaesthe-
tised for an emergency Caesarean section. Following
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