SUN-559 Refractory Thyroid Storm: Role of Single Pass Albumin Dialysis (SPAD)

Abstract

Introduction: Thyroid storm (TS) is a rare, but critical illness that can cause multiorgan failure and carries a high risk of mortality. We describe a case of refractory TS successfully treated with SPAD. Case: A 48 y/o lady was evaluated for sustained ventricular tachycardia (SVT) in the setting of newly diagnosed thyroid storm. She received a left ventricular assist device (LVAD) 4 years ago for cardiomyopathy (EF< 20%). Exam: SVT and florid CHF. Biochemical evaluation following amiodarone infusion for 18 hours: TSH < 0.05 (0.4 - 4 UIU/ml), FT4 7.87(0.76-1.46ng/dl), TT3 181 (60-180 ng/dl). TPO, TRAB and TSI antibodies were negative. Thyroid sonogram showed heterogeneous normal sized gland, no nodules or hyper vascularity. She received methimazole (MMI) 60 mg orally twice daily, Lugol’s iodine 10 drops orally three times daily and hydrocortisone 100mg intravenously 3 times daily. Beta-blockers were deferred due to cardiogenic shock. Amiodarone (400 mg orally twice daily)) was continued for ongoing episodes of SVT. She developed shock liver limiting the continuation of maximum doses of MMI. Continuous veno-venous hemofiltration (CVVH) was initiated for anuric renal failure. She required ventilator and pressor support on day 7 (D7) of hospitalization as urgent preparations were being made for LVAD exchange (given LVAD malfunction). TFts obtained on D7 showed a suboptimal response to maximal therapy: FT4 3.86, TT3 146. She underwent emergent SPAD using modified CVVH with dialysate containing 4% human albumin for 12 hrs. pre-operatively. It led to a fall in the FT4 to 1.71 and TT3 to 90. She received a new LVAD without further episodes of SVT. TFTs subsequent to 8 additional sessions of SPAD (as a bridge to definitive thyroidectomy) were as follows: FT4 1.56, TT3 76, thereby allowing for a dose reduction in MMI. Thyroidectomy was considered but deferred since the family opted for comfort measures when the patient developed cardiac tamponade Conclusions: TS can be recalcitrant to therapy with MMI, beta blockade, cold iodine and steroids. Adjunct therapy such as lithium, cholestyramine, and plasmapheresis, in addition to conventional therapy may have limited benefit, and comes with potential side effects. SPAD offers a safe and effective therapeutic alternative for refractory TS that can be performed continuously for a sustained response. In our case, with SPAD, thyroid hormones dropped to permissible levels, thus allowing for successful completion of emergent high risk cardiac surgery. Additionally, SPAD may provide a window for definitive surgical intervention and should be considered in refractory TS.

Crash Landing of Thyroid Storm: A Case Report and Review of the Role of Extra-Corporeal Systems

“…Parikh et al. ( 33 ) and Koball et al. ( 34 ) illustrated the sequential use of single pass continuous veno-venous albumin dialysis after limited response to TPE, demonstrating a more sustained improvement in thyroid hormones with less rebound thyrotoxicosis, as well as greater removal of thyroid hormones overall.…”

“…Case reports with the use of dialysis has been proposed in management of thyroid storm, most notably with CRRT, which is preferred due to its better tolerability in hemodynamically unstable patients due to its slower rate of exchange of fluids and solutes. Parikh et al (33) and Koball et al (34) illustrated the sequential use of single pass continuous veno-venous albumin dialysis after limited response to TPE, demonstrating a more sustained improvement in thyroid hormones with less rebound thyrotoxicosis, as well as greater removal of thyroid hormones overall. Other studies have shown the additive effects of TPE and CRRT in removal of thyroid hormones (35), while another study reported a correlation of improvement of total T3 and free T4 levels of up to 80% with concomitant CRRT and standard medical therapy (without TPE), although the exact mechanisms are unclear (36).…”