Abstract
Thyroid storm is a rare but life-threatening endocrinological emergency with significant mortality ranging from 10-30% with multi-organ involvement and failure. In view of the rarity of this condition and efficacy of established first line medical treatment, use of extra-corporeal treatments are uncommon, not well-studied, and its available evidence exists only from case reports and case series. We describe a 28-year-old man who presented with an out-of-hospital cardiac arrest secondary to thyroid storm. Despite conventional first-line pharmacotherapy, he developed cardiogenic shock and circulatory collapse with intravenous esmolol infusion, as well as multi-organ failure. He required therapeutic plasma exchange, concurrent renal replacement therapy, and veno-arterial extra-corporeal membrane oxygenation, one of the few reported cases in the literature. While there was clinical stabilization and improvement in tri-iodothyronine levels on three extra-corporeal systems, he suffered irreversible hypoxic-ischemic brain injury. We reviewed the use of early therapeutic plasma exchange and extra-corporeal membrane oxygenation, as well as the development of other novel extra-corporeal modalities when conventional pharmacotherapy is unsuccessful or contraindicated. This case also highlights the complexities in the management of thyroid storm, calling for caution with beta-blockade use in thyrocardiac disease, with close monitoring and prompt organ support.
Highlights
Thyroid storm (TS) is a life-threatening exacerbation of the hyperthyroid state characterized by multi-organ dysfunction of the cardiovascular, thermoregulatory, gastrointestinal-hepatic and central nervous systems
On review of the medical literature of articles in English, there has only been four case reports describing the concurrent use of therapeutic plasma exchange (TPE) and ECMO in patients with thyrotoxicosis with circulatory collapse [4,5,6,7], with one of them reporting the use of three extra-corporeal systems [4]
The cardiovascular effects in TS are driven largely by T3, leading to increased chronotropy and inotropy, improved diastolic relaxation and decreased peripheral resistance, eventually resulting in high cardiac output (CO) heart failure (HF), estimated to be seen in 6% of patients with thyrotoxicosis. This is thought to be reversible with treatment with thyrotoxicosis, with a small study showing improving in left ventricular ejection fraction (LVEF) from 28% to 55% [40]
Summary
Thyroid storm (TS) is a life-threatening exacerbation of the hyperthyroid state characterized by multi-organ dysfunction of the cardiovascular, thermoregulatory, gastrointestinal-hepatic and central nervous systems. Our patient had thyroid storm complicated by thyrocardiac disease, with a Burch-Wartofsky score of 105 His thyroidstimulating hormone receptor antibody eventually returned elevated at >40IU/L (normal ≤2.0IU/L), confirming underlying Graves’ disease. Despite a short downtime of three minutes and prompt cessation of beta-blockade, he required high doses of noradrenaline and vasopressin thereafter He remained persistently hypotensive with maximal dual vasopressor support, and was initiated on VA-ECMO support (Figure 2). His vasopressor support reduced significantly (only requiring low dose noradrenaline infusion) and his triiodothyronine (T3) levels improved (Figure 1). As his FT4 continued to worsen, nasogastric methimazole and Lugol’s iodine were cautiously started, along with second TPE cycle, on the third day. A decision was made in conjunction with his family for withdrawal of care, given the grave prognosis
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