Abstract #1407449: Successful Plasma Exchange and Thyroidectomy in Thyroid Storm

Abstract

Thyroid storm is a severe manifestation of thyrotoxicosis that is defined by hyperthyroidism with multi-organ failure. Typical treatment revolves around decreasing thyroid hormone production and peripheral conversion of T4 to T3. TPE (Therapeutic Plasma Exchange) removes cytokines, antibodies, and thyroid hormones with their bound proteins, but this is mostly a transient option until medications take effect. TPE +/- thyroidectomy is not an ATA (American Thyroid Association) recommended practice but can be considered in individuals. Multiple case reports have been published showing successful resolution of storm with plasmapheresis and surgery if medical management failed or in cases of severe iodine-induced storms. Here, we present a patient in thyroid storm with history of untreated Graves complicated with iodine-induced disease. A 49-year-old male with untreated Graves disease was brought to the hospital after a motor vehicle accident. He underwent multiple contrasted CT studies and found to have several traumatic fractures requiring urgent surgical fixation. In the ER, he was in clinical heart failure with Atrial fibrillation with rapid response, which was treated with an amiodarone drip. He was later found to have suppressed TSH and elevated free thyroid hormones. Full medical treatment for thyroid storm including cholestyramine and steroids was started with initial biochemical improvement for 7 days; however, his thyroid function and clinical status began to deteriorate. During his ICU course, he had worsening Atrial Fibrillation, life-threatening Upper GI bleed with altered mental status which led to his intubation and eventual tracheostomy. We then decided to proceed with TPE and plans for urgent thyroidectomy. He underwent 5 sessions of TPE with nearly a 50% drop in hormones allowing him to be stable enough to undergo a successful total thyroidectomy without surgical complications. Although he did develop presumed catheter associated blood stream infection, it did resolve after antibiotics and central line removal. Soon after, he was discharged to inpatient rehab for ongoing physical therapy. There are currently no ATA guideline recommendations for TPE and thyroidectomy for thyroid storm. In our case, this approach appeared effective in relieving the life-threatening storm our patient presented in. Perhaps, the addition of TPE +/- thyroidectomy after medical treatment failure should be considered earlier for patients with life-threatening thyroid storm and at higher risks for decompensation.