Amiodarone-Induced Thyroid Storm Causing Sustained Monomorphic Ventricular Tachycardia Treated With Plasmapheresis: A Challenging Clinical Case

Abstract

Thyroid storm is a rare endocrine emergency with a high mortality rate approaching 20%. It manifests with the exaggerated symptoms of hyperthyroidism including hyperpyrexia, hypotension, cardiac arrhythmias, and death. The mainstay of treatment includes supportive intensive care and initiation of thionamides, beta blockers, corticosteroids, and if necessary anti-arrhythmics in the presence of refractory ventricular arrhythmias. We describe a case of amiodarone-induced thyrotoxicosis and thyroid storm leading to refractory ventricular tachycardias treated with plasmapheresis when anti-arrhythmic therapy became contraindicated. Amiodarone-induced thyroid storm can lead to monomorphic ventricular tachycardia. Under the circumstances of limited medical therapies, plasmapheresis can be an effective treatment option.

To PLEX or Not to PLEX for Amiodarone-Induced Thyrotoxicosis

“…Thyroid function test should be repeated 2-3 hours after a session of TPE is completed. Our patient's poor response with hemodynamic instability and acute liver injury led to the decision to use PLEX as a bridge to thyroidectomy, despite the recent PEA arrest and critical illness, similar to a case of a patient that presented with sustained monomorphic VT due to AIT [16]. However, despite three PLEX sessions and improvement in TFTs, our patient suffered another cardiac arrest which subsequently led to his demise.…”

“…Despite these therapies, definitive therapy most often entails a thyroidectomy, which may not be feasible in patients presenting in cardiogenic shock, such as our patient. Therefore, the use of PLEX has been reported, to clear amiodarone and thyroid hormones from circulation rapidly [12][13][14][15][16][17]. Notably, despite the growing body of evidence to support PLEX for suspected AIT, patient criteria, timing of initiation of PLEX, and contraindications or considerations to this therapy remain elusive, with conflicting data showing benefit [12][13][14][15][16][17].…”

“…Therefore, the use of PLEX has been reported, to clear amiodarone and thyroid hormones from circulation rapidly [12][13][14][15][16][17]. Notably, despite the growing body of evidence to support PLEX for suspected AIT, patient criteria, timing of initiation of PLEX, and contraindications or considerations to this therapy remain elusive, with conflicting data showing benefit [12][13][14][15][16][17]. Even in the absence of amiodarone as the culprit, guidelines for the optimal role for PLEX in thyroid storm are not well established and the decision to initiate this therapy must be individualized.…”

Therapeutic Plasma Exchange for the Treatment of Hyperthyroidism: Approach to the Patient with Thyrotoxicosis or Antithyroid-Drugs Induced Agranulocytosis

“…In case of failure/intolerance or contraindication of these therapies, as well as in life-threatening situations (including thyroid storm or therapies-induced severe adverse events), therapeutic plasma exchange (TPE) has been proposed as an alternative treatment, based upon extracorporeal systems [ 7 ]. This approach can promptly resolve severe conditions by removing circulating thyroid hormones [ 8 ].…”