Abstract | March 24, 2024
Plasmapheresis as an Alternative Therapy for Thyroid Storm in the setting of Polypharmacy – Related Toxic Metabolic Encephalopathy
Learning Objectives
- The standard treatment of complicated thyrotoxicosis and thyroid storm with the concomitant use of antithyroid medication, iodine, beta-blockers, and corticosteroids is successful in most cases. However, treatment options are limited when anti-thyroidal drugs cannot be used or in cases that are refractory to standard treatment. Plasmapheresis provides a safe and effective strategy when initial treatment fails.
Thyroid storm, a life-threatening complication of thyrotoxicosis, can lead to toxic metabolic encephalopathy. Plasmapheresis, as an alternative intervention, can be considered when conventional treatment methods are contraindicated or ineffective. [1]
A 58-year-old female with a medical history of anxiety, body dysmorphic disorder and hypothyroidism presented with altered mental status. She was currently on psychotropic medications multiple and Levothyroxine.
Upon arrival, the patient’s EKG showed sinus tachycardia, temperature of 37.3°C, heart rate of 129 bm, and blood pressure of 157/117 mmHg. Laboratory results indicated a suppressed TSH level (<0.01) and elevated levels of free T4> 20.00 nanog/d and free T3 free>5.00 pg/ml. A CT scan of the head and a chest X-ray did not reveal any acute abnormalities.
Patient was transferred to the intensive care unit. Endocrinology was consulted, and the patient was initiated on treatment including Precedex, Propranolol, Propylthiouracil, Solu Cortef, and Potassium Iodine. Due to the lack of improvement, third day, plasmapheresis was recommended. The patient underwent two sessions of plasmapheresis 1:1 with 5% albumin and fresh frozen plasma every other day. After the second session, there was clinical improvement. The patient was alert and oriented, no longer agitated or confused, and her vital signs had stabilized. Thyroid hormone levels had normalized. TSH level was found to be 1.65 uIU/ml. She was discharged the following days with continuity of care in the outpatient setting. The patient was provided with a detailed medication plan for continued care.
The case presented highlights the successful use of plasmapheresis as a therapeutic option in a patient with thyroid storm and polypharmacy. The half-life of thyroid hormones is so long that quick improvement is not always achieved even by sufficient doses of antithyroid drugs. Thus, plasma exchange in combination with conventional therapy appears to be effective in relieving the life-threatening state in our patient with thyroid storm precipitated by exogenous thyroid hormone use and polypharmacy.[2] [4] However, further research is needed to better understand the optimal timing, frequency, and long-term outcomes of plasmapheresis in the management of thyroid storm with polypharmacy. Early recognition and intervention are crucial to improve patient outcomes in such cases.
References and Resources
- Galindo RJ, Hurtado CR, Pasquel FJ, García Tome R, Peng L, Umpierrez GE. National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004-2013. Thyroid. 2019 Jan;29(1):36-43. doi: 10.1089/thy.2018.0275. Epub 2018 Dec 18. PMID: 30382003; PMCID: PMC6916241.
- Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii. doi: 10.1016/j.ecl.2006.09.008. PMID: 17127140.
- Muller C, Perrin P, Faller B, Richter S, Chantrel F. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec;15(6):522-31. doi: 10.1111/j.1744-9987.2011.01003.x. PMID: 22107688.
