Coma in Thyroid Storm: Review of Aggregated English-Language Case Reports

Abstract

Context Coma is a serious manifestation of thyroid storm (TS) about which little is known. Objective To describe the features, duration, treatment response, and prognosis of coma in the setting of TS. Design Aggregate analysis of individual English-language case reports of coma in the setting of TS from 1935 to January 2019. Setting Hospitals. Patients Sixty-five cases were identified, 29 from case reports and 36 from case series. Interventions Antithyroid drugs, corticosteroids, beta-blockers, iodine, intubation, plasmapheresis, antibiotics, thyroidectomy, radioiodine, dialysis, and l -carnitine. Main Outcome Measures Awakening and death rates overall and in relation to administered treatments, day of coma presentation, and time from coma onset; symptoms associated with coma; TS and coma scales; thyroid and cerebrospinal laboratory tests; electroencephalogram; brain imaging; and autopsy results. Results Mortality was 38% in the setting of TS-related coma, 11% during the years 1978 to 2019 compared with 70% for 1935 to 1977. Both awakening and death commonly occurred within the first 2 days of coma onset. Reduction in total and free T4 values, and possibly also total T3 value, correlated with awakening from coma. Lower death rates were associated with use of antithyroid drugs, corticosteroids, beta-blockers, and intubation. Plasmapheresis was associated with awakening in 67% of cases but not with lower death rates. Conclusions Prognosis of coma associated with TS remains poor. Current guidelines for the early use of plasmapheresis in unresolving TS are advocated and should be considered urgently at the point of confusion or delirium in an effort to abort coma.

Thyroid storm presenting with coma

“…A combination of propylthiouracil, beta-blockade, Lugol's iodine, corticosteroids and cholestyramine was administered to the patient in our case. This was in keeping with local hospital guidelines and treatment regimens described in similar case reports and review articles [1,3,5,6]. Supportive therapies for the manifestations of decompensated organ failure are also often required, including tracheal intubation and invasive ventilation, antipyretics and vasopressor therapies.…”

“…Cholestyramine may increase the clearance of thyroid hormones by reducing their enterohepatic circulation [1]. In severe or treatment-resistant cases, plasmapheresis has been used [3]. This case highlights the importance of considering thyroid-related disease in critically ill patients.…”

“…Decompensation of affected organ systems will ensue without treatment, manifesting as intravascular volume depletion, cardiac failure, congestive hepatic failure and central nervous system depression [6]. Presentation with coma is rare: a recent review identified only 65 reported cases of thyroid storm associated with coma in 84 years [3]. In most of these patients, coma developed during hospital admission, with only 13 reported cases of coma at presentation to hospital.…”

“…Disturbance of consciousness occurs commonly, most often manifesting as agitation and delirium [2]. Presentation with coma is rare and is thought to indicate more severe disease [3]. Multiorgan failure ensues if left untreated, usually heralded by high-output heart failure and cardiogenic shock [4].…”

Apathetic Thyroid Storm with Cardiorespiratory Failure, Pulmonary Embolism, and Coagulopathy in a Young Male with Graves’ Disease and Myopathy

“…Though commonly associated with acute confusion [ 34 ] or agitation [ 34 ] which resolves within 2 weeks after normalization of thyroid function [ 35 ], thyroid storm might present with protracted loss of consciousness [ 35 ], psychosis [ 36 ], status epilepticus [ 37 ], extreme lethargy [ 10 ], or coma [ 38 ].…”