Thyroid Storm Caused by Inappropriate Use of Levothyroxine in a Patient with Graves' Disease: Case Report and Literature Review
Article Sidebar
Main Article Content
Abstract
Thyroid storm is a rare and life-threatening endocrine emergency characterized by severe manifestations of thyrotoxicosis and multisystem involvement. A high index of suspicion is essential to allow for early recognition and immediate therapeutic intervention. We report the case of a 58-year-old woman with thyroid storm precipitated by a notable combination of multiple contributing factors: acute appendicitis associated with the inappropriate use of levothyroxine in a patient previously diagnosed with Graves' disease. The patient was initially admitted due to diffuse abdominal pain that subsequently localized to the right iliac fossa, accompanied by an episode of diarrhea, presenting a clinical picture of acute appendicitis. She underwent an appendectomy, subsequently evolving with tachycardia, atrial flutter, and agitation. A thyroid storm was then suspected. Laboratory evaluation revealed suppressed thyroid-stimulating hormone and elevated free thyroxine levels. Clinical scoring systems revealed 45 points on the Burch-Wartofsky scale and grade 1 criteria on the thyroid storm score system of the Japanese Thyroid Association. Levothyroxine was promptly discontinued. Treatment with beta-blockers and thyroid hormone synthesis inhibitor was initiated, leading to progressive clinical improvement and hemodynamic stabilization. This case highlights the synergistic role of multiple precipitating factors, including discontinuation of antithyroid treatment, inadequate exogenous administration of levothyroxine, and surgical stress to trigger a thyroid storm. Furthermore, this report underscores the risks associated with inappropriate prescription of thyroid hormones and reinforces the importance of adequate management of Graves’ disease, particularly in the perioperative setting.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors retain the copyright of their articles and grant the journal the right of first publication under the Creative Commons Attribution (CC BY) license, which allows others to share and adapt the work with proper attribution.
References
Farooqi S, Raj S, Koyfman A, Long B. High risk and low prevalence diseases: Thyroid storm. Am J Emerg Med 2023;69:127–35. https://doi.org/10.1016/j.ajem.2023.03.035.
Kopp PA, Giordani I, Feldt-Rasmussen U, Forget-Renaud A. Approach to the patient with thyroid storm. J Clin Endocrinol 2026;111.
Akamizu T. Thyroid Storm: A Japanese Perspective. Thyroid® 2018;28:32–40. https://doi.org/10.1089/thy.2017.0243.
Inman BL, Long B. Thyrotoxicosis. Emerg Med Clin North Am 2023;41:759–74. https://doi.org/10.1016/j.emc.2023.06.005.
Uwumiro F, Arji E, Okpujie V, Asaju F, Egemonye O, Eyiah N, Falade I, Anasiudu E, Asogwa S, Gbajumo F, Sule R, Agyei A, Andibanbang F, Makinde A, Akanmode O. National Trends in US Hospitalizations and Outcomes of Thyrotoxicosis With and Without Thyrotoxic Storm, 2016 to 2020. J Clin Endocrinol Metab 2025;110:3084–96. https://doi.org/10.1210/clinem/dgaf150.
Galindo RJ, Hurtado CR, Pasquel FJ, García Tome R, Peng L, Umpierrez GE. National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004–2013. Thyroid 2019;29:36–43. https://doi.org/10.1089/thy.2018.0275.
Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical Features and Hospital Outcomes in Thyroid Storm: A Retrospective Cohort Study. J Clin Endocrinol Metab 2015;100:451–9. https://doi.org/10.1210/jc.2014-2850.
Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid® 2016;26:1343–421. https://doi.org/10.1089/thy.2016.0229.
Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263–77.
Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, Monden T, Kouki T, Otani H, Teramukai S, Uehara R, Nakamura Y, Nagai M, Mori, For The Japan Thyroid Association M. Diagnostic Criteria, Clinical Features, and Incidence of Thyroid Storm Based on Nationwide Surveys. Thyroid® 2012;22:661–79. https://doi.org/10.1089/thy.2011.0334.
Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, Kanamoto N, Otani H, Furukawa Y, Teramukai S, Akamizu T. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition): The Japan Thyroid Association and Japan Endocrine Society Taskforce Committee for the establishment of diagnostic criteria and nationwide surveys for thyroid storm [Opinion]. Endocr J 2016;63:1025–64. https://doi.org/10.1507/endocrj.EJ16-0336.
Bourcier S, Coutrot M, Kimmoun A, Sonneville R, De Montmollin E, Persichini R, Schnell D, Charpentier J, Aubron C, Morawiec E, Bigé N, Nseir S, Terzi N, Razazi K, Azoulay E, Ferré A, Tandjaoui-Lambiotte Y, Ellrodt O, Hraiech S, Delmas C, Barbier F, Lautrette A, Aissaoui N, Repessé X, Pichereau C, Zerbib Y, Lascarrou J-B, Carreira S, Reuter D, Frérou A, Peigne V, Fillatre P, Megarbane B, Voiriot G, Combes A, Schmidt M. Thyroid Storm in the ICU: A Retrospective Multicenter Study. Crit Care Med 2020;48:83–90. https://doi.org/10.1097/CCM.0000000000004078.
De Mul N, Damstra J, Nieveen Van Dijkum EJM, Fischli S, Kalkman CJ, Schellekens W-JM, Immink RV. Risk of perioperative thyroid storm in hyperthyroid patients: a systematic review. Br J Anaesth 2021;127:879–89. https://doi.org/10.1016/j.bja.2021.06.043.
Shao P, Li J, Ma D, Wu A, Jiang J. Thyroid storm in a patient with unknown hyperthyroidism during nonthyroidal surgery—a case report and literature review. BMC Anesthesiol 2024;24:417. https://doi.org/10.1186/s12871-024-02801-5.
Zeng J, Yang T, Wu L. Thyroid storm during the recovery phase after non-thyroid surgery in a hyperthyroid patient: a case report and literature review. Front Surg 2025;12:1633314. https://doi.org/10.3389/fsurg.2025.1633314.
Waldegrave SRW. Evidence based medicine: what it is and what it isn’t n.d.
Auchus RJ. The Dark Side of hormone prescription. Endocr Connect 2021;10:C1–3. https://doi.org/10.1530/EC-21-0039.
Irwig MS, Fleseriu M, Jonklaas J, Tritos NA, Yuen KCJ, Correa R, Elhomsy G, Garla V, Jasim S, Soe K, Baldeweg SE, Boguszewski CL, Bancos I. Off-Label Use and Misuse of Testosterone, Growth Hormone, Thyroid Hormone, and Adrenal Supplements: Risks and Costs of a Growing Problem. Endocr Pract 2020;26:340–53. https://doi.org/10.4158/PS-2019-0540.
Skrzypiec-Spring M, Kujawa K, Wietrzyk A, Matuła P, Materna M, Michalska W, Szumny D, Szeląg A. Poisoning with Thyroid Hormones Used Illegally—Systematic Review. Pharmaceuticals 2025;18:1808. https://doi.org/10.3390/ph18121808.
Maury E. A thyrotoxicosis outbreak due to dietary pills in Paris. Ther Clin Risk Manag 2008;Volume 4:1375–9. https://doi.org/10.2147/TCRM.S4110.
Hartung B, Schott M, Daldrup T, Ritz-Timme S. Lethal thyroid storm after uncontrolled intake of liothyronine in order to lose weight. Int J Legal Med 2010;124:637–40. https://doi.org/10.1007/s00414-010-0423-y.
Du F, Liu S-W, Yang H, Duan R-X, Ren W-X. Thyrotoxicosis after a massive levothyroxine ingestion: A case report. World J Clin Cases 2022;10:3624–9. https://doi.org/10.12998/wjcc.v10.i11.3624.
Jabbar A, Pingitore A, Pearce SHS, Zaman A, Iervasi G, Razvi S. Thyroid hormones and cardiovascular disease. Nat Rev Cardiol 2017;14:39–55. https://doi.org/10.1038/nrcardio.2016.174.
Klein I. Thyroid Hormone and the Cardiovascular System n.d.
Frost L, Vestergaard P, Mosekilde L. Hyperthyroidism and Risk of Atrial Fibrillation or Flutter. ARCH INTERN MED 2004;164.
Inoue K, Guo R, Lee ML, Ebrahimi R, Neverova NV, Currier JW, Bashir MT, Leung AM. Iodine-Induced Hyperthyroidism and Long-term Risks of Incident Atrial Fibrillation and Flutter. J Clin Endocrinol Metab 2023;108:e956–62. https://doi.org/10.1210/clinem/dgad250.
Lee SY, Modzelewski KL, Law AC, Walkey AJ, Pearce EN, Bosch NA. Comparison of Propylthiouracil vs Methimazole for Thyroid Storm in Critically Ill Patients. JAMA Netw Open 2023;6:e238655. https://doi.org/10.1001/jamanetworkopen.2023.8655.
Isozaki O, Satoh T, Wakino S, Suzuki A, Iburi T, Tsuboi K, Kanamoto N, Otani H, Furukawa Y, Teramukai S, Akamizu T. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol (Oxf) 2016;84:912–8. https://doi.org/10.1111/cen.12949.
Matsuo Y, Miyawaki A, Watanabe H, Matsui H, Fushimi K, Yasunaga H. Potassium Iodide Use and Patient Outcomes for Thyroid Storm: An Observational Study. J Clin Endocrinol Metab 2025;110:e310–20. https://doi.org/10.1210/clinem/dgae187.
Senda A, Endo A, Tachimori H, Fushimi K, Otomo Y. Early administration of glucocorticoid for thyroid storm: analysis of a national administrative database. Crit Care 2020;24:470. https://doi.org/10.1186/s13054-020-03188-8.