8005 Life-Saving Therapeutic Plasma Exchange in Three Patients With Thyroid Storm and Acute Liver Failure
Authors: Cicogna Julia Isabel Richter , Hajnal Sofia Pannunzio , Barsotti Fellipe Vidal , Silva Eliane Ribas Tameirao , de Oliveira Martins Graziela , de Lemos Manuela Nascimento , Buchpiguel Marina , Scalissi Nilza Maria , Lima-Jr Jose Viana 
Published: October 2024

Disclosure: J.R. Cicogna: None. S.P. Hajnal: None. F.V. Barsotti: None. E.R. Silva: None. G.D. Martins: None. M.N. Lemos: None. M. Buchpiguel: None. N.M. Scalissi: None. J.V. Lima-Jr: None.

Thyroid storm is a rare complication of hyperthyroidism characterized by multi-organ dysfunction, including liver failure. Treatment involves antithyroid drugs (ATD); however, when contra-indicated or life-threatening complications require obtention of rapid euthyroidism, Therapeutic Plasma Exchange (TPE) is an effective bridge to definitive treatment. Case 1: A 22-year-old female presented with a 10-day history of progressive jaundice. She had been self-medicating with Valeriana officinalis (V. officinalis). On admission, she was lethargic, febrile, and tachycardic, and presented exophthalmos and goiter. Laboratory workup revealed AST = 1908 U/L (reference value [RV] 14-36), ALT = 1800 U/L (RV &lt;35), total bilirubin of 13.7 mg/dL (RV 0.2-1.3). Diagnosis of acute liver failure and thyroid storm were made, later confirmed by TSH &lt; 0.008µU/ml (RV 0.4-4.3) and free T4 = 8.66ng/dl (RV 0.7-1.8). After investigation, including a liver biopsy, diagnosis of toxic hepatitis due to V. officinalis was made. TPE was initiated and after the fourth session the patient was stable, allowing a successful thyroidectomy. Case 2: A 28-year-old female presented with a 20-day history of abdominal pain, jaundice, diarrhea, and fecal acholia. She also presented tachycardia and altered mental status and was diagnosed with thyroid storm. Laboratory workup showed AST = 1722 U/L, ALT = 1821 U/L, INR 1,55 (RV 0.8-1.2), and total bilirubin of 5,5 mg/dL, indicating liver failure. TSH was 0.01 µU/ml and free T4 was 7.8 ng/dl; TRAb was 14,6 IU/L (0-1.75). Further investigation revealed autoimmune hepatitis. She underwent four sessions of TPE followed by radioiodine therapy. The patient was discharged asymptomatic. Case 3: A 51-year-old female with type 1 diabetes and hyperthyroidism is admitted with diabetic ketoacidosis and a Burch-Wartofsky score of 70, culminating into cardiorespiratory arrest. After resuscitation, she presented heart failure, pancreatic dysfunction, and severe liver failure. Laboratory workup revealed TSH &lt;0,001 UI/mL and T4L 4,05 ng/dL. She was treated with two sessions of TPE, which allowed definitive treatment with radioiodine.Elevation of liver enzymes is an expected presentation of thyroid storm; however, acute liver failure is rare. When present, it should prompt investigation of other causes. Despite the cause, it is not advisable to use ATD when liver function is severely altered. In this setting, TPE must be considered since, besides being a treatment option for thyrotoxicosis, it is also therapeutic for toxic and autoimmune hepatitis and was shown to improve transplant-free survival in critically ill patients with liver failure. In this case series we report three cases of thyroid storm associated with acute liver failure, both conditions successfully treated with TPE. This is the first known case of thyroid storm associated with acute liver failure due to V. officinalis toxicity.

Presentation: 6/2/2024