Severe Hyperthyroidism Complicated by Agranulocytosis Treated with Therapeutic Plasma Exchange: Case Report and Review of the Literature

Abstract

Aim To present a case of Graves' disease complicated by methimazole induced agranulocytosis treated with therapeutic plasma exchange (TPE) and review of the literature. Case Presentation A 21-year-old patient with a history of Graves' disease presented to the endocrine clinic. His history was significant for heat intolerance, weight loss, and tremors. Upon examination he had tachycardia, smooth goiter, thyroid bruit, and hyperactive reflexes. He was started on methimazole and metoprolol and thyroidectomy was to be done once his thyroid function tests normalized. On follow-up, the patient symptoms persisted. Complete blood count done showed a white blood cell count of 2100 (4000–11,000 cells/cu mm) with a neutrophil count of 400 cells/cu mm, consistent with neutropenia. He was admitted to the hospital and underwent 3 cycles of TPE and was also given filgrastim. He improved clinically and his thyroxine (T4) levels also came down. Thyroidectomy was done. He was discharged on levothyroxine for postsurgical hypothyroidism. Conclusion Plasmapheresis may be useful in the treatment of hyperthyroidism. It works by removing protein bound hormones and also possibly inflammatory cytokines. Further studies are needed to clarify the role of various modalities of TPE in the treatment of hyperthyroidism.

Effective Preoperative Plasmapheresis Treatment of Severe Hyperthyroidism in a Patient with Giant Toxic Nodular Goiter and Methimazole-Induced Agranulocytosis

“…Plasmapheresis has been described in medical literature as being able to control severe hyperthyroidism when other treatments cannot be used or are ineffective [ 9 , 11 , 14 ], as was the case in our patient. Use of a therapeutic plasmapheresis procedure in the context of treating hyperthyroidism was first described in 1970 by Ashkar et al [ 11 , 30 ]. During the procedure, a significant volume of plasma is exchanged, which contains toxins and numerous proteins (including antibodies and immune complexes, among others).…”

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

“…One literature review studied the use of plasmapheresis for patients in thyrotoxicosis with contraindications to medical management. Fifty-six patients were treated with plasmapheresis and all but one showed biochemical and/or clinical improvement in symptoms (16). One single institution study from Turkey established that TPE resulted in a decline of fT4 from a median of 2.9 to 1.6 ng/dL in 46 patients through a variable number of treatment sessions from 1 to 7, though the majority of these patients had a fT4 level we would have deemed safe for surgery (17).…”

“…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).…”

Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure: A case report

“…The PTU was replaced with MMI, and transaminases then decreased. Both Eisen and Lock reported severe hepatotoxicity after using 300 mg PTU for just 1 d[14,15]. PTU-related liver failure can occur at any time over the course of therapy.…”

“…TPE is an extracorporeal blood purification technique designed for rapid removal of harmful plasma constituents or to decrease the concentrations of antibodies and immune complexes[14,17]. It is a well-established and effective therapeutic option in many diseases and has been used successfully to treat severe hyperthyroidism in recent years[18,19].…”