The Burch-Wartofsky Point Scale (BWPS) for diagnosis of TS, proposed in , is an empirically derived scoring system, which considers the. With regard to diagnostic criteria for TS, few have been published other than those by Burch and Wartofsky (3,5). Their criteria are useful, but the approach taken. Work-Up; Burch & Wartofsky Diagnostic Criteria. 5 Management. Supportive care; Treat Increased Adrenergic Tone; Block.

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Thyroid storm TS is life threatening. Its incidence is poorly defined, few series are available, and population-based diagnostic wartofsk have not been established. We identified patients with TS1 and 74 patients with TS2. Based qnd these data and information from the Ministry of Health, Labor, and Welfare of Japan, we estimated the incidence of TS in hospitalized patients in Japan to be 0. The mortality rate was Multiple organ failure was the most common cause of death in TS1 and TS2, followed by CHF, respiratory failure, arrhythmia, disseminated intravascular coagulation, GI perforation, hypoxic brain syndrome, and sepsis.

Glasgow Coma Scale results and blood urea nitrogen BUN were associated with irreversible damages in 22 survivors. We present newly formulated diagnostic criteria for TS and clarify its clinical features, prognosis, and incidence based on nationwide surveys in Japan.

This information will help diagnose TS and in understanding the factors contributing to mortality and irreversible complications. T hyroid storm TS is a life-threatening condition requiring emergency treatment 1 — 3.

The condition arises in thyrotoxic patients and is manifested by the decompensation of multiple organs, which is often triggered by severe stress. Since its pathophysiologic mechanisms have not been clarified, the diagnosis of TS is based on clinical manifestations. Some of the characteristic clinical manifestations include unconsciousness, high fever, heart failure, diarrhea, and jaundice. With regard to diagnostic criteria for TS, few have been published other than those by Burch and Wartofsky 35.

Their criteria are useful, but the approach taken, by utilizing the summation of multiple clinical manifestation scores, may often reach the threshold for the diagnosis of TS in thyrotoxic patients with severe nonthyroid illness, but not necessarily with TS.

Furthermore, the scores that are allocated to signs and symptoms in this diagnostic ans are complex and have not been validated. In the context of this information, the Japan Thyroid Association organized a committee that developed diagnostic criteria for TS and surveyed its incidence in Japan, linking the research activities of both the Wartosfky Endocrine Society and the Ministry of Health, Labor, and Welfare of Japan.

Thyrotoxicosis vs. Thyroid Storm? A Scoring System

Here, we the members of this committee, report our findings regarding the clinical features of TS and propose diagnostic criteria for TS.

Our criteria were based on an analysis of the literature, followed by a survey of the thyrotoxic patients in Japan who had the features of TS as reported in the literature. We finalized our criteria based on the clinical features and course of these patients. In addition, we sought to provide data regarding the incidence of TS in Japan.

The present study was approved by the ethics committee of the Jichi Medical University.

Since TS is rare, a prospective study that develops criteria was considered very difficult and time consuming. Therefore, the criteria were mainly based on information obtained from wxrtofsky literature.

Ninety-three original case reports see Supplementary Databurvh online at www. Seven unpublished cases of TS diagnosed in the researchers’ facilities were also included in the analysis. The individual clinical parameters extracted from these cases were analyzed. Next, we examined the prevalence of various clinical features in these patients and compared these to the corresponding prevalence in our patients with thyrotoxicosis but without TS Tox-NoTS. We also analyzed the patterns of combinations of clinical manifestations.

Patterns were stratified by the presence or absence of central nervous system CNS manifestations, because these were most frequent and appeared to wrtofsky very specific to TS. We recruited them from either our outpatient clinics or inpatient wards in a serial manner over a period of several months.


The first part of the survey shows the questionnaire that the respondents were asked to fill in Appendix B. SURVEY-1 also collected information regarding gender and the year patients were seen but did not ask for clinical details. In accordance with the Nationwide Epidemiologic Survey Manual 6 — 8we selected hospital departments of internal medicine, endocrinology, thyroidology, cardiology, and emergency medicine as the targets for SURVEY Study hospitals were randomly selected from a list of all the hospitals in Japan.

In our documents, this was referred to as the Second Nationwide Survey. After the responses to SURVEY-2 had been received, we organized and analyzed the information provided, initially entering this into a database.

To fill gaps in the data provided for individual patients, we directly contacted responders to obtain this information. Using these validated data, we analyzed the content of the database, including information regarding clinical features and the number of patients from reporting bufch. Differences in clinical manifestations among patients with TS1, TS2, and Tox-NoTS patients were analyzed by the analysis of variance or ane chi-squared test, as appropriate.

The comparison between the BWC-TS and our diagnostic criteria for TS were assessed with logistic regression, Spearman rank correlation, and the chi-squared test Fisher’s exact testrespectively.

To identify the factors independently associated with clinical outcomes, logistic regression analysis or multiple regression analysis with the stepwise method was used as appropriate after the possible relevant factors had been selected by simple regression analysis. The clinical outcomes that scoe evaluated were death, irreversible complications, and severity of thyroid crisis.

Thyroid storm – WikEM

Information regarding these 99 cases and 7 of our unpublished cases are summarized in Table 1 see first column. Table 1 also contains information on the clinical characteristics of Tox-NoTS patients. In Tox-NoTS patients, the most prominent clinical characteristics were tachycardia, goiter, weight loss, and finger tremor.

All patients with TS that had CNS manifestations exhibited at least one or other of the clinical characteristics of TS which were prominent in the literature. Since none of these manifestations showed any evident correlation with one another, it was considered that each manifestation could be dealt with independently.

Systeme International SI units for free T4 to picomoles per liter conversion factor, Based on the findings just mentioned, we attempted to establish cut-off values for each manifestation to obtain better sensitivity, specificity, and predictive values. With regard to CNS manifestations, the mild symptom, agitation, was excluded. Therefore, the criteria for CHF were limited warrtofsky relatively severe manifestations: These were arrived at by a consensus burxh are presented in Appendix Aafter the questionnaire.

Burch-Wartofsky Point Scale (BWPS) for Thyrotoxicosis – MDCalc

One of the purposes of SURVEY-1 for cases of TS1 and TS2 among patients admitted for the treatment of thyrotoxicosis was to obtain a 5-year estimate of their incidence in Japan during the years through In a group of randomly selected hospitals, there was a However, 7 patients were reported twice. The ages of patients with TS1 and TS2 were The ages of men and women with TS1 and TS2 were similar data not shown.

This was followed by very rare cases of destructive thyroiditis five cases. The highest trigger of TS was the irregular use or discontinuation of the patient’s antithyroid drug, and the second highest trigger was infection, particularly that of the upper respiratory tract data not shown. The combined mortality rate znd patients with TS1 and TS2 was The mortality rates of TS1 and TS2 were The age of patients who died from TS1 and TS2 was The duration between the initial diagnosis of Graves’ disease and the onset of thyroid storm is summarized in the upper panel.

The number of patients who developed thyroid storm within one year after the initial diagnosis of underlying thyroid disease is shown in the lower panel. The wartofsjy serum free thyroxine FT4 concentration in patients with TS1 was 6.


The mean serum free triiodothyronine FT3 warrofsky in patients with TS1 was The range of body temperatures was Dashed lines show the limits of reference ranges. The distribution of the heart rate is presented in Figure 4. Although agitation was found in More than half of the patients with TS1 Fig.

In these 40 patients, there were 4 fatalities.

Predictive features associated with thyrotoxic storm and management

Thirty-five of the 55 patients with TS1 who did not have CNS manifestations would have warttofsky assigned to the TS2 category if they had not had jaundice. Considering patients with TS1 and TS2, the mortality rate in patients with a total bilirubin level more than 3.

Severe features of CHF were present in Although leg edema and pleural effusions were generally the most frequent signs of CHF, logistic regression analysis showed that their contribution to the diagnosis of TS1 or TS2 was not significant data not shown. Atrial fibrillation AF was observed in Significantly, AF occurred in Among patients with TS1 and TS2, the occurrence of any one of the five major groups of clinical manifestations CNS, fever, tachycardia, CHF, and GI-hepatic did not positively correlate with the occurrence of any other group of clinical manifestations Table 4.

A logistic regression analysis nurch the diagnosis according to the new criteria as ranking variables revealed that the BWC-TS score 35 made a significant contribution to differentiating between our patients categorized as TS1 or TS2 and our Tox-NoTS patients. The contribution was estimated to be However, a multiple logistic regression analysis revealed that the comorbidities of shock OR: Among the survivors, 22 were reported as having irreversible damage of some kind with brain damage occurring in 6, disuse atrophy occurring in 5, cerebrovascular disease occurring in 4, renal insufficiency occurring in 2, and psychosis occurring in 2.

In three patients, the irreversible damage was not specified. To differentiate clinically between TS1 and TS2, we analyzed the prognosis of each syndrome in terms of mortality and irreversible defects. In fatal cases, the independent risk factors for mortality were not different between the two syndromes TS1 vs.

However, when these analyses were limited to the irreversible neurological defects, including hypoxic brain damage, disuse atrophy, cerebrovascular disease, and psychosis, patients with TS1 had a higher prevalence of irreversible neurological defects than patients with TS2 TS1 vs. As is evident from the diagnostic criteria for each syndrome, the clinical differences between TS1 and TS2 are the presence of neurological symptoms and ensuing defects.

We sought to determine how severely ill patients with TS were, or were perceived to be, based on svore indices. One was the level of inpatient care they were assigned to, this being an intensive care unit, a high care unit, or the general wards. The dead exhibited significantly higher scores than brch of the survivors in both score methods: In a multiple logistic regression analysis, the inpatient level of care was significantly related to the GCS levels OR: Possible factors contributing to the severity and prognosis of thyroid storm.

First, we examined the prevalence and independence of clinical manifestations of these patients and of Tox-NoTS patients, including analyses of combinations of clinical features. Next, we investigated whether the cut-off wratofsky for each manifestation provided appropriate sensitivity, specificity, and predictive values to differentiate between TS1, TS2, and Tox-NoTS.

Based on these analyses, we made only one change to generate the final diagnostic criteria for TS. This was related to the serum bilirubin concentration. Notably, none of these three patients died in TS.