Iatrogenic thyrotoxicosis and the role of therapeutic plasma exchange

Abstract

Thyroid storm or severe thyrotoxicosis results from extreme thyroid hormone elevation. Therapy includes medical management to prevent hormone production, release, recycling, and peripheral conversion while stabilizing adrenergic tone. Thyroid dysfunction is the usual cause but it can be due to excessive thyroid hormone ingestion. Therapeutic plasma exchange (TPE) has been used to rapidly remove protein-bound thyroid hormone. American Society for Apheresis guidelines make a weak recommendation to perform TPE in selected patients in the treatment of thyrotoxicosis based on low quality evidence. We present a case of excessive thyroid replacement hormone ingestion treated by TPE. The patient presented with the clinical picture of thyroid storm, including cardiovascular compromise and massively elevated total and free T3 (525 ng/dL, nl 80-200 ng/dL and 28 pg/mL, nl 2.0-3.5 11 pg/mL), which failed medical therapy. A single, one plasma volume TPE was performed. Both total and free T3 demonstrated substantial declines immediately after TPE with the patient's mental status returning to near-normal. Thyroid hormone extraction efficiency and collection efficacy were calculated as 37.1% and 40.8%, respectively. Prior to discharge on day 6, the patient's compounding pharmacy indicated that a "bad batch" of bovine thyroid gland derived replacement hormone had been produced. TPE appears to be effective in removing protein bound thyroid hormone in extreme iatrogenic thyrotoxicosis.

Graves’ disease thyrotoxicosis and propylthiouracil related agranulocytosis successfully treated with therapeutic plasma exchange and g-csf followed by total thyroidectomy.

“… 13 Recently, TPE has been successfully used also in a case of extreme iatrogenic thyrotoxicosis due to excessive thyroid replacement hormones ingestion showing a rapid decline of total and free T3 and symptoms resolution. 14 …”

“…For this reason close and repeated plasma exchange sessions (in our case 6 over 12 days) were necessary to obtain a result and, therefore, this therapeutic option cannot be considered as the only curative treatment in these situations. 8 – 14 Nevertheless, TPE can be a lifesaving procedure to obtain a transitional euthyroid state before complete thyroidectomy with minimal risk of thyroid storm or surgical bleeding induced by thyroid tissue hypervascularization.…”

Therapeutic Plasma Exchange as a Bridge to Total Thyroidectomy in Patients with Severe Thyrotoxicosis

“…Patients who experience side effects of ATDs, namely agranulocytosis and hepatotoxicity, require an alternate treatment modality (1). In those with severe thyrotoxicosis and impending storm requiring hospitalization, therapeutic plasma exchange (TPE) has been used to acutely manage thyrotoxicosis and thyroid storm as a bridge to thyroidectomy; however, the role of TPE in routine management has not been adequately established (category III) by the American Society of Apheresis (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15).…”

Weathering the storm: A case of thyroid storm refractory to conventional treatment benefiting from therapeutic plasma exchange

“…Evidence supporting the use of therapeutic plasma exchange (TPE) in the management of TS has appeared in a number of case reports and case series over the last 48 years. [5][6][7][8][9][10][11][12][13][14][15] However, the limited incidence of TS makes the performance of prospective randomized control trials difficult; thus, limited high-quality evidence exists to support the use of TPE in TS. Consequently, the American Society of Apheresis classifies the use of TPE for TS as a Category III recommendation, meaning that the role of apheresis in this clinical context has not been established.…”

“…Nevertheless, some patients remain refractory to these conventional treatments or have contraindications to their use. Evidence supporting the use of therapeutic plasma exchange (TPE) in the management of TS has appeared in a number of case reports and case series over the last 48 years . However, the limited incidence of TS makes the performance of prospective randomized control trials difficult; thus, limited high‐quality evidence exists to support the use of TPE in TS.…”