Thyroid Storm Deaths Rose With Covid-19, Other Risk Factors
Orlando, Fla — A surge in mortality due to thyroid storm occurred in the US during 2020-2021, likely partially, but not entirely, due to the COVID-19 pandemic, a new analysis of people hospitalized with thyrotoxicosis in the National Inpatient Sample (NIS) between 2016 and 2021 showed.
However, 'the increased mortality observed was not solely attributable to COVID-19 infection. Critical comorbid conditions markedly heightened the risk of death,' study author Muhammad Sohaib Asghar, MD, a resident physician at AdventHealth, Sebring, Florida, told Medscape Medical News .
'This underscores the importance of early recognition and aggressive management of thyrotoxicosis, especially during healthcare system stressors such as pandemics,' said Asghar.
The condition — an endocrine emergency of extreme hyperthyroidism — commonly occurs in people with Graves' thyrotoxicosis but is often precipitated by a secondary inciting factor such as infection or cardiac event, explained co-study author, Shehar Bano, MD, a resident physician at AdventHealth, Sebring, Florida, who presented the results at American Association of Clinical Endocrinology (AACE) Annual Meeting 2025.
Racial and demographic factors appeared to play a role in the development of thyroid storm among those with thyrotoxicosis, with higher rates among ethnic minorities and those of lower socioeconomic status, Bano added.
Given the high mortality risk in patients with thyrotoxicosis with severe systemic illness, Asghar noted, 'clinicians should prioritize early risk stratification and consider prompt escalation of care. Tailored treatment plans and closer monitoring of patients with high-risk features can potentially improve outcomes, particularly in resource-limited or high-stress clinical settings.'
'These findings highlight the need for a multidisciplinary approach and proactive management of comorbidities in this patient population,' he added.
Thyrotoxicosis Trends: Many Risk Factors Identified
The study population included individuals aged 18 years or older in the NIS who had ICD-10 codes for thyrotoxicosis (E.05) regardless of cause, excluding those with a concomitant diagnosis of thyroiditis. Of the 186,474 patients included in the analysis (mean age, 60.91 years; 73% women), 97.83% were discharged alive while 2.17% died in hospital.
A total of 3800 patients with thyroid storm (2.04% of the study population) were identified. Patients with thyroid storm were significantly younger (mean age, 47 years vs 61 years), had greater lengths of hospital stay (7 days vs 5 days), and higher inflation-adjusted cost of stay ( P < .001).
There was no gender predisposition in relation to thyroid storm ( P = .61), but those with it were more likely Black or Hispanic individuals ( P < .01), and to be on Medicaid or self-paying. They were also more likely to live in low socioeconomic ZIP codes ( P < .01) and the US South region ( P < .01), and to be admitted in Government non-federal hospitals ( P < .01).
Those with thyroid storm were significantly more likely to have a long list of concurrent diagnoses, including coagulopathy, drug abuse, history of heart failure with systolic component instead of diastolic, mild liver disease, peripheral vascular disease, weight loss, sepsis, septic shock, cardiogenic shock, rheumatic heart disease, and non-ST-elevation myocardial infarction ( P < .001 for all).
The list also included atrial arrythmias, respiratory failure, invasive ventilation, tracheostomy, cardiac arrest, acute heart failure, pneumonia, use of mechanical circulatory support, supraventricular and ventricular tachycardia, mitral valve disease, chronic liver disease, percutaneous endoscopic gastrostomy tube placement, acute venous thromboembolism, and pericardial effusion/pericarditis ( P < .001, except for pneumonia where P = .001).
Over the entire study period, age-adjusted mortality per 100,000 hospitalizations was 6825 among those with thyroid storm vs 3601 for those without, Bano reported.
For those with thyroid storm, in-hospital mortality appeared to be rising even prior to the COVID-19 pandemic, with a surge beginning in 2019. The percentages were 2.88% in 2016, 6.00% in 2017, 4.78% in 2018, 6.37% in 2019, 6.61% in 2020, and 7.58% in 2021 ( P for trend < .001).
Among those without thyroid storm, in-hospital mortality stayed relatively steady until the pandemic, ranging from 1.78% to 1.82% between 2016 and 2019, then jumping to 2.48% in 2020 and 2.87% in 2021 ( P for trend < .001).
Annual age-adjusted mortality rates per 100,000 hospitalizations were roughly similar between those with and without thyroid storm in 2019, 3442 and 3107, respectively. In 2020, those numbers rose to 7629 for those with thyroid storm vs 4754 for those without. In 2021, they were 12,859 and 4539, respectively.
'With future National Inpatient Sample data releases in 2023 and beyond, we should expect this mortality rate to be declining,' Asghar told Medscape Medical News .
Impressive Sample Size
Asked to comment, session moderator Sean Ho Yoon, MD, assistant professor of clinical medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, New York, told Medscape Medical News , 'the study has a limitation because it is not randomized, case controlled, or even blinded. It is a retrospective study. So there's an inherent confounding.'
But, Yoon added, those limitations were somewhat mitigated by the large sample size from NIS, which includes 86% of healthcare centers in the US.
'I was impressed by the fact that the sample size is really big. Thyrotoxicosis may be commonly seen, but thyroid storm is not,' he said. Having a 3800-patient sample size 'was actually impressive.'
Regarding the socioeconomic differences, Yoon said, 'For clinicians, the challenge is the barriers for them to have access to healthcare because thyroid storm, especially, is preventable by just following routinely with doctors and taking the medication or definitive treatment for the hyperthyroidism.'
Bano, Asghar, and Yoon have no disclosures.
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Massachusetts is one of a few states that don't have a default surrogate appointment process. If an incapacitated patient has not designated someone to make medical decisions for them, the hospital automatically takes over, said Thaddeus Pope, a bioethicist and professor at the Mitchell Hamline School of Law in Minnesota. 'There are a lot of reasons to do the proxy,' Pope said. 'Not just because there won't be anybody (to make decisions). But because the list might put the wrong person in charge.' The Bakers said they told the hospital that Baylie would never want to live in that condition. But even though they understand the hospital was following the law, it didn't make the pain any easier. 'Basically, they said the hospital has guardianship of your daughter. The ethics committee has guardianship of her. So any decisions made have to go through them,' Shawnee Baker said. 'Do you have any idea of the salt to the wound for a mother when your child is lying there and they tell you that the hospital now has guardianship?' Massachusetts General Hospital declined to comment, citing privacy issues. So once again, the Bakers had to fight – this time for Baylie's right to die. Without a proxy telling them whether to turn off the machines keeping Baylie alive, the hospital appointed an ethics team to determine her fate. After some back-and-forth between the Bakers and the hospital the ethics committee relented, and doctors turned off Baylie's machines on September 27. Shawnee Baker said it's what Baylie would have wanted. She'd had a conversation with her daughter about the topic the year before, she said. 'She said, 'Mom, you know there's some things worse than dying.' And I said, 'What do you mean?' And she said, 'Being trapped in a body that doesn't work. Don't ever let that happen to me, mom. Promise me.'' The Bakers hope their ordeal will help educate other families about the health care maze facing young adults. In May, Shawnee Baker published a book, 'Baylie,' about her daughter's story. Some of the proceeds will go to the family's Baylie's Wish Foundation, which advocates for safety for college students and educates parents on health care proxies, she said. Until her daughter's accident, Shawnee Baker said she'd never heard about health care proxies. 'Parents only focus on, 'Is this a good school, and do you have the grades to get into this school?' And we worry about the dorm room. We don't look into safety and other policies,' she said. The Bakers also teamed up with 3rd-i, a tracking app designed to make rideshares and other public outings safer. With the app, users share live video, audio, location and their destination to one or more groups of people they create on the platform. In emergency situations, a tap on a SOS button shares the user's livestream and location with dispatchers — allowing them to act fast, said Dillon Abend, the app's founder. The Bakers believe the app could have made a big difference in keeping Baylie safe that night. About a month into Baylie's coma, her mother wrote her a letter. 'I prayed for weeks that you'd come back to me, but now I'm praying for you to let go and fly with the angels,' it said. 'Heaven is beautiful … you can ride horses all day long. Become a butterfly, my darling, and fly free.' Baylie was gone not long after. Shawnee Baker lost her only daughter at the time but has since welcomed two others. Baylie wanted to be a neurosurgeon so she could help others. And her parents believe she'd want them to share her story to save others from similar heartache. Shawnee Baker said grief has given her a purpose: To be the change for good that her daughter never got to be.
