A Case of Thyroid Storm with Multiple Organ Failure Effectively Treated with Plasma Exchange

Abstract

We describe a 48-year-old man with thyroid storm presenting with heart failure. He presented severely impaired left ventricular wall motion and a marked increase in the liver enzymes. He developed disseminated intravascular coagulation on day 2. Due to elevated serum thyroid hormone level, anti-thyroid hormone receptor antibody positivity, and his clinical symptoms, he was diagnosed as thyroid storm due to untreated Graves' disease. His condition did not improve even after 6 days of conventional therapy including steroids. After therapeutic plasma exchange was carried out, his thyroid hormone level decreased markedly. Consequently, his condition recovered gradually, and he was discharged at day 43.

A rare cause of fever and icterus: Thyroid crisis

“…The case is more common among women than in man 5-10 times and it generally is seen in elderly. 2,6,8 Examination showed no finding of thyroid disease or exophthalmos. On very rare occasion, thyroid crisis can appear without any clinical findings (goiter, exophthalmia) and history of thyrotoxicosis.…”

“…It is though that the level of serum lactate dehydrogenase, transaminase and bilirubin increase because of hepatic dysfunction and cardiac ischemic hepatitis. 8,13 There are some reports of severe cholestatic hepatitis. 3 Hepatitis and hepatotoxicity should be considered in differential diagnosis.…”

Perfect storm: Therapeutic plasma exchange for a patient with thyroid storm

“…Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established. 21 There are a limited number of cases in the literature, [8][9][10][11][12][13][14][15][16][17][18][19][20] including one case demonstrating its use as a bridge toward definitive surgical treatment in a patient that could not attain euthyroid state. 11 TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines.…”

“…There are 13 cases of therapeutic plasma exchange (TPE) for thyroid storm or severe thyrotoxicosis in the literature. [8][9][10][11][12][13][14][15][16][17][18][19][20] In 1 case, a patient with congestive heart failure and supraventricular tachyarrythmia developed thyroid storm following administration of amiodarone, failed standard therapy for thyroid storm, and subsequently received TPE with an initial improvement in clinical state. However, the improvement was not sustained and the patient passed away from cardiac failure.…”

“…19 The remaining 12 cases of TPE for thyroid storm in the literature all demonstrated improved clinical response and decreased thyroid hormones following TPE. [8][9][10][11][12][13][14][15][16][17][18]20 However, TPE remains an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established. 21 Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines 8 and is likely beneficial for these patients.…”