Objective : Thyroid storm is a severe manifestation of thyrotoxicosis and can present with multi-organ failure. First line treatment of thyroid storm is directed towards decreasing thyroid hormone production and peripheral conversion of T4 to T3 and treating adrenergic symptoms. When medical therapy fails, plasmapheresis is an alternative treatment option. Plasmapheresis successfully reduces T3 and T4 levels in patients unresponsive to medical therapy. According to The American Society for Apheresis, the role of plasmapheresis in thyroid storm is not established and the decision to use plasmapheresis for this indication should be individualized. Here we present a patient with thyroid storm and multi-organ failure who was treated with plasmapheresis.
Methods : A 50-year-old male with a history of hyperthyroidism, hypertension, and congestive heart failure presented with fever and altered mentation. Imaging revealed a right lower lobe pneumonia and antibiotics were started. He developed shock complicated by atrial fibrillation with rapid ventricular rate which was treated with amiodarone. He was transferred to our hospital for further management. TSH on arrival was 7ng/dL and total T3 was 358ng/dL. Hydrocortisone 50mg every 6 hours and methimazole (MMI) 10mg TID were started. Endocrinology recommended increasing MMI to 30 mg TID and starting cholestyramine 4g TID. The next day, SSKI 250 mg TID was added. His hospital course was complicated by transaminitis, respiratory failure requiring intubation, shock requiring vasopressor support, kidney failure requiring continuous renal replacement therapy, and heart failure with an ejection fraction of 30%. When the transaminitis improved, MMI was switched to PTU 200 mg TID. Despite maximal anti-thyroid therapy, he had not improved clinically and T4 and T3 remained markedly elevated.
Results : A 4-day course of plasmapheresis was initiated which resulted in marked lowering of T4 and T3.
Discussion : His clinical course significantly improved. He was discharged home 3 weeks later.
Conclusion : While current guidelines for plasmapheresis for thyroid storm recommend individualized decision making, no further clarification is provided on who would be a good candidate for the procedure. In our report, we present a patient with thyroid storm and multi-organ failure who was treated with plasmapheresis after failing maximal medical therapy. Given his significant improvement, endocrinologists should have a lower threshold to treat thyroid storm with plasmapheresis when patients are not improving with medical therapy alone.
University of Maryland
Ann is a first year endocrinology fellow at the University of Maryland.