Refractory thyrotoxicosis induced by iodinated contrast agents treated with therapeutic plasma exchange. A case report

Pasimeni, Giuseppe; Caroli, François-Xavier; Spriano, Giuseppe; Antonini, Mario; Baldelli, Roberto; Appetecchia, Marialuisa

doi:10.1002/jca.20161

Cited by 29 publications

(23 citation statements)

References 22 publications

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“…However, in patients with iatrogenic thyrotoxicosis or for whom antithyroid drugs are contraindicated or who are resistant to antithyroid drugs, further therapies are needed to restore euthyroid hormone status. The reported cases suggested that therapeutic plasma exchange (TPE) has been used as an additional treatment or preparation for surgery [5][6][7].…”

Section: Introductionmentioning

confidence: 99%

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

Ezer

Çalışkan

Parlakgümüş

et al. 2009

J of Clinical Apheresis

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The purpose of this report was to determine the effectiveness of therapeutic plasma exchange (TPE) in preoperative preparation of patients with thyrotoxicosis scheduled for either thyroid or nonthyroid surgery. We retrospectively reviewed 11 patients with thyrotoxicosis and those who prepared surgery with plasmapheresis between 1999 and 2008 at our institution. Ten patients underwent thyroid surgery and one patient was operated for femur fracture during antithyroid drug treatment. The indications for plasmapheresis in all patients with severe thyrotoxicosis were poor response to medical treatment (seven patients), agronulocytosis due to antithyroid drugs (three patients), iodine-induced thyrotoxicosis (Jodd Basedow effect in one patient), and rapid preparation for urgent orthopedic operation (one patient). After TPE, we observed a marked decrease in free thyroxin (FT3) and free triiodothyronin (FT4) levels; however, the decline in the biochemical values were not statically significant (P > 0.62, P > 0.15). Although both FT3 and FT4 levels remained above the normal limits in two of 11 patients, the signs and symptoms of thyrotoxicosis improved in all patients and no thyroid storm observed during the perioperative period. TPE can be considered a safe and effective alternative to prepare patients with thyrotoxicosis for surgery when drug treatment fails or is contraindicated and when emergency surgery is required.

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Section: Introductionmentioning

confidence: 99%

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

Ezer

Çalışkan

Parlakgümüş

et al. 2009

J of Clinical Apheresis

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“…The definitive therapeutic treatment for thyroid storm is to perform surgical thyroidectomy or radioactive iodine treatment to prevent recurrence of symptoms and the associated mortality. It is preferred that patients attain a euthyroid state prior to undergoing surgery . Data demonstrates that euthyroid patients have decreased thyroid vascularity and improved surgical planes and that thyrotoxic patients experience significant perioperative mortality due to precipitation of thyroid storm .…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

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

McGonigle

Tobian

Zink

et al. 2017

J of Clinical Apheresis

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Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8-2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8-1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.

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“…It has been used in preoperative and post-operative management of severely hyperthyroid patients with contraindications to antithyroid drugs (13). It has also been used for the management of TS, predominantly in patients with Graves' disease with ophthalmopathy (14,15) or agranulocytosis (16,17) and in selected patients with toxic multinodular goiter (18). In a recent case of TS, plasmapheresis was done post surgery, where sleeve pneumonectomy was the precipitating event and the patient had not responded to standard antithyroid treatment (19).…”

Section: Discussionmentioning

confidence: 99%