SURVIVING THE STORM: USE OF THERAPEUTIC PLASMA EXCHANGE IN THYROID STORM

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thyroid storm is a severe, life threatening exacerbation of thyrotoxicosis. It is characterized biologically by extremely elevated levels of circulating thyroid hormone and multiorgan dysfunction. Even with treatment, thyroid storm related mortality is 30%, it is mostly associated with cardiac arrhythmias and progressive cardiomyopathy. Initial treatment is aimed at treating the adrenergic symptoms, reducing the thyroid hormone production and peripheral conversion of thyroxine to triiodothyronine. We present a patient with thyroid storm who failed maximal conventional medical management and clinically improved only after multiple sessions of therapeutic plasma exchange (TPE). CASE PRESENTATION: A 60-year-old female with past medical history of Grave's disease presented to the hospital for shortness of breath, palpitations and bilateral lower extremity edema for past 3 days. Patient reported being diagnosed with Grave's disease 2.5 years and noncompliance with her medications. On presentation, she was in atrial fibrillation with rate in 200's, was given 12 mg and 6 mg of intravenous (iv) adenosine and started on iv diltiazem drip. Her Burch - Wartofsky score was 60, indicative of thyroid storm. She was also treated with oral propranolol 60 mg every 6 hours, oral propylthiouracil (PTU) 150 mg every 8 hours and oral prednisone 20 mg every 12 hours. Initial labs revealed TSH: <0.005 UIU/mL, free T3: 26.93 pg/mL, Total T3: >650 ng/dL and Total T4: 24.52 mcg/mL , which improved to free T3: 5.47 pg/mL, free T4: 5.62 ng/dL ,TSH <0.005 UIU/mL and thyroid stimulating immunoglobulin(TSI): 455 after antithyroid medications. Patient failed desynchronized cardioversion for her rapid Atrial fibrillation. She underwent 4 sessions of TPE and she converted to sinus rhythm after the second session. Post TPE, labs revealed free T4: 1.90 ng/dL, free T3: 3.17 pg/mL, suppressed TSH <0.005 UIU/mL. She was discharged on oral PTU and oral prednisone with follow up with the endocrinologist in 2 weeks. DISCUSSION: During TPE, thyroid-binding globulin and bound thyroid hormones are removed with the plasma. Then the colloid replacement (albumin) provides new binding sites for circulating free thyroid hormone. TPE was used successfully in our patient, resulting in a decline of both free T3 and Free T4 and improvement of her symptoms. Given the significant and rapid improvement in our patient, TPE can be considered in the treatment course of thyroid storm when antithyroid medications fail to ameliorate the symptoms. CONCLUSIONS: In severe cases of thyroid storm when conventional medical therapy has failed, TPE should be considered as a treatment option. Reference #1: Plasmapheresis in Thyroid storm, Riham Elmahboubi, MD resident Journal of the Endocrine Society, Volume 3, Issue Supplement_1, April-May 2019, SUN-573, https://doi.org/10.1210/js.2019-SUN-573 DISCLOSURES: No relevant relationships by Anvitha Ankireddypalli, source=Web Response No relevant relationships by Harsh Mehta, source=Web Response No relevant relationships by Praveen Kumar Vikraman, source=Web Response