8232 Therapeutic Plasma Exchange as a Bridge to Total Thyroidectomy in a Patient with Refractory Thyroid Storm
Authors: Sridhar Archana , Chaudhary Taibah , Kaur Ravleen , Patil Shreyas , Prabha Kumar Arathi , Djekidel Karim , Jameson Brian C 
Published: October 2024

Abstract
Disclosure: A. Sridhar: None. T. Chaudhary: None. S. Patil: None. A. Prabha Kumar: None. K. Djekidel: None. B.C. Jameson: None.
Background: Thyroid storm is a rare life-threatening complication of hyperthyroidism with a mortality rate of 10-30%. Therapeutic plasma exchange (TPE) could be a bridge to definitive total thyroidectomy in patients with refractory disease who fail conventional therapy. Clinical case: Patient is a 31-year-old male with a past medical history of untreated hypertension, anxiety, alcohol use, substance abuse and a family history of Graves’ disease. He presented with complaints of breathing difficulty, back and shoulder pain for the past 1 day. In the ED he was found to be in respiratory distress with a rate of 40/min. He was started on a non-rebreather mask and was eventually intubated due to worsening distress. He was tachycardic with a heart rate of 130/min and had elevated blood pressure at 170/105 mm Hg. Physical examination was significant for diaphoresis, accessory respiratory muscle use, and diffuse swelling on the front of the neck. His blood work was significant for hemoglobin 11.1g/dL, TSH &lt;0.01 uIU/mL, FT3 &gt;32.6 pg/ml, FT4&gt;7.8 ng/dL and urine drug screen was negative. Chest X-ray showed mild perihilar vascular congestion due to pulmonary edema. CT neck showed nonspecific diffuse enlargement of the thyroid gland without dominant thyroid nodule. The patient was admitted to the ICU for management of thyroid storm likely from Graves’ disease. Burch-Wartofsky Point Scale score on admission was 60. Endocrinology was consulted and the patient was started on IV hydrocortisone 100 mg and IV Methimazole 20 mg every 8 hours, propranolol 60 mg every 6 hours, and iodine drops 300 mg every 6 hours after the first dose of methimazole. Since repeat FT4 after 48 hours showed no improvement, he was switched to Propylthiouracil (PTU) with a loading dose of 500mg every 4 hours for 2 doses followed by 250 mg every 6 hours and cholestyramine 4 g orally 4 times daily to reduce enterohepatic circulation of thyroid hormone. After 3 days of PTU, the patient’s FT3 was improving but FT4 continued to be elevated. ENT was consulted for total thyroidectomy, but the patient required preparation to improve FT4 levels prior to surgery. He was transferred to a tertiary care center on Day 6 of admission to undergo TPE. After 3 sessions of TPE serum FT3 and FT4 decreased, patient’s mentation improved, and he was extubated on Day 10 of admission. He received a total of 5 sessions of TPE and underwent total thyroidectomy on Day 15 of admission without complications. Postoperatively he was started on oral Levothyroxine 125 mcg once daily and calcitriol 0.25 mcg twice daily. Patient continues to follow up with Endocrinology clinic for thyroid function monitoring and medication adjustment. Conclusion: Given the high mortality rate associated with thyroid storm, early recognition of refractory disease is imperative. Bridging with TPE while awaiting total thyroidectomy improved clinical outcomes in our patient and should be considered in such cases.
Presentation: 6/3/2024