Thyroid Storm in the Absence of Gastrointestinal Access: A Case of Therapeutic Plasma Exchange

Introduction: Thyrotoxicosis, particularly in its severe form as thyroid storm, is a life-threatening endocrine emergency requiring prompt intervention. Standard treatment involves antithyroid drugs (ATDs) given either orally or rectally, beta-blockers, saturated solution of potassium iodide (SSKI), and corticosteroids. However, in patients with critical illness and compromised gastrointestinal (GI) access, such as those with ischemic bowel or anastomotic complications, alternative treatments must be considered. This report highlights the challenges and therapeutic strategies in managing thyrotoxicosis without GI access.


Description: A 46-year-old woman with a history of intermittently controlled Graves’ disease presented for elective ileostomy reversal. On postoperative day 1, she exhibited tachycardia, hyperthermia, and agitation. Laboratory analysis revealed severe thyrotoxicosis with undetectable TSH and elevated free T4 of 5.99 ng/dL [nl: 0.89-1.76]. Standard treatment was initiated until the patient decompensated with septic shock necessitating bowel resection, remaining in discontinuity, and with an open abdomen. Due to the location of the resections, anatomy precluded oral or rectal ATD administration. She developed hypotension requiring 3 pressors, therefore beta blockade was stopped, leaving her only treatment as SSKI and intravenous hydrocortisone. Due to persistent thyrotoxicosis and clinical instability, therapeutic plasma exchange (TPE) was initiated. After two sessions, free T4 levels normalized (from 3.26 ng/dL —> 2.38 —> 1.65) and her clinical status improved, allowing for eventual definitive surgical management.


Discussion: This case underscores the complexity of managing thyrotoxicosis in patients without GI access. Intravenous corticosteroids provide partial suppression of peripheral T4 to T3 conversion but are insufficient alone in severe cases when ATDs cannot be used. TPE offers a rapid, effective method to reduce circulating thyroid hormones and is particularly valuable when conventional therapies are contraindicated or ineffective. However, it requires specialized resources and carries procedural risks. Early recognition of the need for alternative therapies and multidisciplinary coordination are critical in such scenarios.