Thyroid storm (TS) is a rare, but critical illness that can cause multiorgan failure and carries a high risk of mortality. We describe a case of refractory TS successfully treated with the novel modality of SPAD
Methods : A 48 y/o lady is evaluated for sustained ventricular tachycardia (SVT) in the setting of newly diagnosed thyroid storm. She received left ventricular assist device (LVAD), 4 yrs. ago for nonischemic cardiomyopathy (EF< 20%) Exam revealed VT (140/min) and pedal edema. Biochemical evaluation s/p amiodarone infusion for 18 hrs. : TSH < 0.05 (0.4 - 4 UIU/ml), Ft4 7.87(0.76-1.46ng/dl), TT3 181 (60-180 ng/dl); liver, renal function tests and WBC were unremarkable.TFts drawn 6 months prior were WNL. TPO, TRAB and TSI antibodies were negative. Thyroid sonogram: heterogeneous normal sized gland, no nodules or hyper vascularity. She received methimazole (MMI) 60 mg PO bid, lugol’s iodine 10 drops tid, and stress dose steroids for a week, beta-blockers were deferred due to cardiogenic shock. Amiodarone (400 mg PO bid) was continued for ongoing episodes of SVT. Hospital course was complicated by shock liver limiting the continuation of max dose of MMI and initiation of continuous veno-venous hemofiltration (CVVH) for anuric renal failure. She required ventilator and pressor support starting day 7 (D7) of hospitalization as urgent preparations were being made for LVAD exchange (given LVAD malfunction). TFts obtained on D7 showed suboptimal response to maximal therapy: Ft4 3.86, TT3 146.
Emergent SPAD using modified CVVH with dialysate containing 4% human albumin was performed for 12 hrs. preoperatively, and it led to a fall in Ft4 1.71 and TT3 90. She received a new device, without further episodes of SVT. Tfts subsequent to 8 additional sessions of SPAD (as bridge to definitive thyroidectomy) were as follows: Ft4 1.56, TT3 76, thereby allowing for dose reduction in MMI. Thyroidectomy was considered but deferred since the family opted for comfort measures when she developed cardiac tamponade on postop D8.
Discussion : TS can be recalcitrant to therapy with MMI, beta blockade, cold iodine and steroids. Adjunct therapy such as lithium, cholestyramine, and plasmapheresis, in addition to conventional therapy may have limited benefit. SPAD offers a safe and effective therapeutic alternative for refractory TS that can be performed continuously for a sustained response
In our case, with SPAD, thyroid hormones dropped to permissible levels, thus allowing for successful completion of emergent high risk cardiac surgery. Additionally, it may provide a window for definitive surgical intervention and should be considered in refractory TS.
Tanvi Parikh– Endocrinology Fellow, Georgetown University Hospital, Silver Spring, Maryland