The standard management for Graves thyrotoxicosis includes the use anti-thyroid drugs, surgery and radioactive iodine treatment. In certain situations,alternative methods including bile acid sequestrants and therapeutic plasma exchange (TPE) have proven effective especially when other treatment modalities fail. We describe a case where conventional and alternative non-invasive measures failed to restore an euthyroid state and resorted to emergency thyroidectomy. A 49 years old female was referred signs and symptoms consistent with Graves thyrotoxicosis. She was already started on pulse IV methylprednisolone for active thyroid eye disease. Her thyroid functions tests showed a suppressed TSH of <0.05 mIU/l (0.274.2),free T4 of 52.7 pmol/l (10.021.0) and free T3 of 18 pmol/l (3.56.5). Her Thyroid receptor antibodies were high of >100 IU/l (1.01.8). She was started on anti-thyroid drugs which were stopped due to side effects. She had active thyroid eye disease so radioiodine was not appropriate and surgery considered the best option. She failed to block on Potassium iodide, and surgery was cancelled due to hyperthyroidism. She was started on Steroids and Cholestyramine but failed to respond with worsening symptoms and biochemistry. As a last resort, therapeutic plasma exchange was initiated with improvement in her thyroid biochemistry but no resolution despite seven sessions. An emergency total thyroidectomy was rearranged as the final resort with steroid and B-blocker cover. Fortunately, the surgery was uneventful and she made an uneventful recovery with subsequent improvement in her thyroid functions and clinical symptoms. This case demonstrates how Gravess thyrotoxicosis can pose a clinical challenge when it is refractory to all medical therapies including plasma exchange. Total thyroidectomy remains the best and only option, a comprehensive multidisciplinary approach involving an endocrinologist, a surgeon and an anaesthetist is crucial to optimize the outcome and reduce the risk of thyroid storm.
20 - 23 May 2017
European Society of Endocrinology