THERAPEUTIC USE OF PLASMA EXCHANGE IN THYROID STORM REFRACTORY TO CONVENTIONAL TREATMENT

Abstract

INTRODUCTION
Thyroid storm is a serious life-threatening condition resulting from uncontrolled hyperthyroidism with mortality rates reaching 30%. First-line treatment includes high doses of propylthiouracil, methimazole, potassium iodide, beta blockers, steroids, radioactive ablation and thyroidectomy. Patients poorly tolerant or have contraindications to medical therapy, or poor surgical candidates may require alternative treatments. Therapeutic plasma exchange (TPE) is a potential modality by rapidly removing thyroid hormones, antibodies and cytokines in plasma; it is listed by the American Society of Apheresis (ASFA) as Class III indication; its optimal role has not been established and initiation, based on the latest American Thyroid Association (ATA) 2016 guidelines, has mainly focused on patients responding poorly to traditional therapeutic measures.

CASE
We report a 49-year-old female in thyroid storm presenting as fever, jaundice, tachycardia, and diarrhea who was unable to tolerate both propylthiouracil and methimazole, and was a poor surgical candidate. TPE was performed for one cycle while propylthiouracil initiated at a lower dose. Over the treatment course, thyroid hormones normalized [FT3 (23.91 to 2.30 pmol/L) and FT4 decreased (64.35 to 13.18 pmol/L)]. However, symptoms progressed: sinus rhythm became atrial fibrillation, sensorium deteriorated to comatose, and was persistently hypotensive despite vasopressors. She eventually expired on her 7th hospital day from multiorgan failure.

CONCLUSION
TPE having only transient effects in thyroid hormone levels should ideally be used in conjunction with antithyroid medications and initiated early in the setting of clinical deterioration, without waiting for the effects of conventional treatment to take effect.