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

Abstract

BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis, characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases, such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure. CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting, diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure. Moreover, she also suffered from heart failure. Therapeutic plasma exchange (commonly known as TPE) and continuous renal replacement therapy (commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests. CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.

Therapeutic plasma exchange for control of thyroid storm

“…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. 26 The mechanism by which CRRT reduces thyroid hormone and leads to clinical improvement is unclear.…”

“…26 Most patients in these case reports had multiorgan failure and the main indications for initiating CRRT was fluid removal or oliguric renal failure. 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.…”

“…CRRT has been used in the management of thyroid storm in a limited number of case reports 26 . Most patients in these case reports had multiorgan failure and the main indications for initiating CRRT was fluid removal or oliguric renal failure 26,27 . CRRT may be combined concurrently with TPE 27‐29 or in isolation 26 .…”

Intractable hiccups as a rare gastrointestinal manifestation in severe endocrine and metabolic crisis: case report and review of the literature

“…In the hyperthyroid state, the insulin level decreases because of the increase in the glomerular filtration rate, 43,52 and the ratio of C-peptide to proinsulin is very low. 38,53 These factors aggravate the underlying abnormal glucose metabolism and intensify insulin deficiency, which in this case served as a trigger for the onset of DKA. It has been reported that the identification of TS tends to be delayed in patients with DKA because of suppression by fever 13,44,45 and relatively low thyroid hormone levels.…”

“…11 The literature related to TS was searched from 2016 to 2019, and the clinical characteristics of gastrointestinal symptoms in patients with TS were found to mainly be nausea, and the main cause of TS to be Graves' disease with unknown or poor compliance with anti-thyroid drugs (Table 3). [33][34][35][36][37][38][39][40][41][42][43][44][45][46] Considering that hiccups are not common in either DKA or TS, we speculate that the incidence of intractable hiccups is rare when DKA overlaps with TS. By carefully searching the literature, we found the following related cases.…”