Rethinking Our PLEXit Strategy in Thyroid Storm: When to Cut Our Losses on Medical Therapy Alone

Introduction: Thyroid storm is an acute life-threatening syndrome defined as severe hyperthyroid symptoms (fever, tachyarrhythmia, altered mental status, heart failure, or diarrhea) with multi-organ dysfunction and a reported mortality rate of 20-30%. Medical therapy includes methimazole or propylthiouracil, beta blocker, iodine, glucocorticoids, and cholestyramine. In refractory cases, Plasma Exchange (PLEX) may be considered, though no treatment guidelines exist.


Description: A 44 year old woman with no known medical history presented to our hospital with dyspnea, fever, and palpitations. She was found to be in atrial fibrillation with rapid ventricular response, had an elevated lactate, and had signs of pleural effusion on chest radiograph. Shortly after arrival, the patient became somnolent and hypotensive requiring admission to the cardiac ICU. Further workup revealed an undetectable TSH and a markedly elevated free T3 (22.3) and T4 (7.4), with signs of end organ damage with lactic acidosis, transaminitis, and anuria. Despite treatment for thyroid storm with methimazole, esmolol, potassium iodide, hydrocortisone, and cholestyramine, she continued to deteriorate with worsening shock requiring multiple vasopressors, liver and kidney failure, and was subsequently intubated. Given the lack of rapid response to medical therapy and ongoing hemodynamic instability, therapeutic PLEX was considered. Unfortunately before initiation, the patient's hemodynamics continued to worsen. The family opted to pursue comfort measures and the patient passed shortly after.


Discussion: Multiple case reports have shown the benefits of PLEX in rapidly decompensating patients in thyroid storm. PLEX works by rapidly removing circulating protein-bound thyroid hormones and serves as a temporizing measure to help bridge patients to thyroidectomy. PLEX is often a last resort due to limited data for its use. We argue that PLEX should be considered earlier in medically refractory cases, such as in our patient, whose acute liver failure likely disrupted thyroid metabolism. Prompt initiation of PLEX could be a life-saving measure, and this case illustrates the importance of considering this intervention earlier in medically refractory thyroid storm.