Endocrine Abstracts

JOINT2253

Introduction: Thyrotoxic crisis is a rare, life-threatening emergency. Early diagnosis and prompt management reduces morbidity and mortality. We, hereby, report the case of a patient presenting with low GCS secondary to thyroid storm and consequently developed multi organ failure. Due to lack of clinical response to conventional treatment, plasmapheresis was carried out with a favorable outcome.

Case Presentation: A 65-year-old lady was diagnosed with hyperthyroidism while an inpatient in mental health care for worsening bipolar disorder. Two weeks later, she was transferred to our hospital with chest infection. She was withdrawn and non-compliant therefore, anti-thyroid treatment was frequently interrupted. Her condition rapidly deteriorated and she was transferred to ITU with respiratory failure and GCS of 7/15. Her HR was 148/min, BP-170/90 mmHg, RR-54/min, temperature 38.3⁰C. She fulfilled the criteria for diagnosis of thyrotoxic storm as per Burch Wartofsky point scale (BWP) and Japan thyroid association (JTA). Her TSH was <0.05 µIU/ml; T4 61 ng/dl, T3 16 pg/ml. TRAb 9.6 IU/l. She was intubated and started treatment immediately including Propylthiouracil, Lugol’s Iodine, Propranolol, Hydrocortisone and Cholestyramine. Then she developed type II myocardial infarction, complicated by acute kidney and liver injury due to cardiogenic shock in addition to coagulopathy. GCS remained low despite normal CT head and EEG. Conventional treatment failed to control her thyroid function after 6 days, so plasma exchange was commenced. She became euthyroid after 2 sessions. She successfully underwent total thyroidectomy. Her GCS started improving 7 days post-operatively and she was successfully weaned off ventilator and discharged.

Discussion: Thyroid storm is a rare presentation of hyperthyroidism with high mortality. The exact mechanism of this condition remains poorly understood. A potential explanation is reduced affinity of TBG for T4 leading to an increased level of freeT4. Moreover, an increase in target cell-β-adrenergic receptor or change in the signalling pathways can result in increased sensitivity to stimulation. Therapeutic plasma exchange (TPE) has been successfully utilised in a variety of diseases. It’s a safe procedure, with overall incidence of adverse effects around 5%. Its use in treating thyrotoxic crisis has been demonstrated in a few case reports and case series globally. Despite its proven effectiveness, TPE is not yet included in recently published guidelines on management of thyrotoxicosis suggesting the need for further evaluation. However, in cases when conventional measures fail, plasmapheresis is a reasonable safe option to decrease circulating thyroid hormone levels and should be considered as a stabilising measure.