Successful treatment of thyroid storm presenting as recurrent cardiac arrest and subsequent multiorgan failure by continuous renal replacement therapy

Abstract

SummaryThyroid storm is a rare and potentially life-threatening medical emergency. We experienced a case of thyroid storm associated with sepsis caused by pneumonia, which had a catastrophic course including recurrent cardiac arrest and subsequent multiple organ failure (MOF). A 22-year-old female patient with a 10-year history of Graves’ disease was transferred to our emergency department (ED). She had a cardiac arrest at her home and a second cardiac arrest at the ED. Her heart recovered after 20 min of cardiac resuscitation. She was diagnosed with thyroid storm associated with hyperthyroidism complicated by pneumonia and sepsis. Although full conventional medical treatment was given, she had progressive MOF and hemodynamic instability consisting of hyperthermia, tachycardia and hypotension. Because of hepatic and renal failure with refractory hypotension, we reduced the patient’s dose of beta-blocker and antithyroid drug, and she was started on continuous veno-venous renal replacement therapy (CRRT) with intravenous albumin and plasma supplementation. Subsequently, her body temperature and pulse rate began to stabilize within 1 h, and her blood pressure reached 120/60 mmHg after 6 h. We discontinued antithyroid drug 3 days after admission because of aggravated hyperbilirubinemia. The patient exhibited progressive improvement in thyroid function even after cessation of antithyroid drug, and she successfully recovered from thyroid storm and MOF. This is the first case of thyroid storm successfully treated by CRRT in a patient considered unfit for antithyroid drug treatment.Learning points:The presenting manifestations of thyroid storm vary and can include cardiac arrest with multiorgan failure in rare cases.In some patients with thyroid storm, especially those with severe complications, conventional medical treatment may be ineffective or inappropriate.During thyroid storm, the initiation of CRRT can immediately lower body temperature and subsequently stabilize vital signs.Early initiation of CRRT can be life-saving in patients with thyroid storm complicated by MOF, even when used in combination with suboptimal medical treatment.

Therapeutic plasma exchange for control of thyroid storm

“…26,27 CRRT may be combined concurrently with TPE [27][28][29] or in isolation. 26 When used with TPE, case reports have showed clinical improvement and a reduction of FT4 by 44% to 80% and TRAb by 70% after 3 to 4 days of CRRT and TPE. [27][28][29] The only case report of CRRT used in isolation demonstrated a reduction of FT4 by 80% and near normalization of FT4 after 1 week of CRRT.…”

“…[27][28][29] The only case report of CRRT used in isolation demonstrated a reduction of FT4 by 80% and near normalization of FT4 after 1 week of CRRT. 26 The mechanism by which CRRT reduces thyroid hormone and leads to clinical improvement is unclear. 26 While TPE can remove molecules with a molecular mass greater than 65 kDa, 30 CRRT can only remove molecules of up to 35 kDa by diffusion and convection through the dialysis membrane.…”

“…26 The mechanism by which CRRT reduces thyroid hormone and leads to clinical improvement is unclear. 26 While TPE can remove molecules with a molecular mass greater than 65 kDa, 30 CRRT can only remove molecules of up to 35 kDa by diffusion and convection through the dialysis membrane. 31 Therefore, CRRT would neither remove bound thyroid hormones (molecular weight 66 kDa when bound to TBG) nor TRAb which has a molecular weight of 660 kDa.…”

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

“…Thus, we performed CRRT initially to alleviate symptoms of heart failure and improve life-threatening conditions. CRRT involves continuous dialysis and filtration to facilitate the slower removal of fluids and solutes, which is well tolerated and results in fewer metabolic changes in critically ill patients[21]. This approach has advantages in terms of cardiovascular stability, which is suggested as a therapeutic measure in patients with heart failure.…”

A Rapidly Fatal Case of Lactobacillus Rhamnosus Sepsis Associated with Thyroid Storm in an Immunocompetent Patient

“…However, it is rare and remains potentially a life-threatening medical emergency. A case of thyroid storm associated with sepsis caused by pneumonia, which had a catastrophic course including recurrent cardiac arrest and subsequent MOF was reported last year [22]. The incidence of MOF in thyroid storm has been reported to be 9% and considered to be an independent risk factor for mortality [2].…”