RF23 | PSAT301 Plasmapheresis and Extracorporeal Membrane Oxygenation (ECMO) for Treatment of Thyroid Storm with Multiorgan Failure
Authors: Chugh Radhika , Harkens Wiley 
Published: November 2022

Abstract

Introduction
Thyroid storm is a life-threatening condition with a high morbidity and mortality rate. It can lead to severe end organ damage including liver injury, which can preclude the use of thionamides. Therapeutic plasma exchange can be a lifesaving option for treatment of thyroid storm in such cases. Multiorgan failure can also necessitate the use of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT).

Case Presentation
A 34-year-old woman with a history of Graves’ disease, untreated for several years, presented to the emergency department with fatigue, palpitations, dyspnea, and edema which developed over 1 month. Labs showed suppressed thyroid stimulating hormone (TSH) with significantly elevated free T4 of 10.8 ng/dL (normal 0.89-1.76 ng/dL). She had evidence of atrial fibrillation and heart failure. She was started on treatment with propylthiouracil, propranolol, and hydrocortisone and then Lugol's iodine was added. However, she quickly deteriorated with worsening mentation, dyspnea, and hypotension. She progressed to multiorgan failure including significant liver injury likely due to ischemic hepatitis. Thus, thianomides could not be used any further. She was started on cholestyramine; hydrocortisone and Lugol's iodine were continued.An echocardiogram revealed global hypokinesis with a left ventricular ejection fraction of 20%. Beta blockers were discontinued due to hypotension. The cardiogenic shock worsened despite aggressive medical therapy requiring initiation of veno-arterial (V-A) ECMO. She also required CRRT due to renal failure.Plasmapheresis was initiated for treatment of thyroid storm and she received 4 treatments with normalization of free T4: 1.48 ng/dL and T3 levels: 3.4 ng/dL (normal 2.3-4.2 ng/dL). Her condition subsequently improved and she was decannulated from the ECMO device after 5 days. She was then able to receive definitive treatment with thyroidectomy 11 days following admission. The patient was discharged in improved condition after a 10-week hospital course.

Discussion
Thyroid storm is a rare complication of thyrotoxicosis with a mortality rate of 10-30%. Treatment classically involves inhibiting the synthesis, release, and peripheral conversion of thyroid hormone as well as supportive management. Major causes of mortality in thyroid storm, present in our patient, include cardiogenic shock, arrhythmia, and multiorgan failure. Cardiac and hepatic failure can preclude the use of beta blockers and thionamides, which may necessitate the use of extracorporeal treatments, such as plasmapheresis for clearance of high burden of circulating thyroid hormone; V-A ECMO and CRRT for end organ damage. These therapeutic measures were used in our patient and led to a favorable outcome. This case highlights the successful use of these extracorporeal treatments as a bridge to thyroidectomy when standard medical treatment is contraindicated or unsuccessful.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:42 p.m. - 12:47 p.m.