MON-365 - Plasma Exchange in Thyroid Storm-Induced Cardiogenic Shock and Multiorgan Failure

Background:
Thyroid storm is an endocrine emergency that can cause multiorgan failure. Therapeutic plasma exchange (TPE) has been used as rescue therapy when conventional treatment is ineffective or contraindicated. Data on TPE in patients requiring mechanical circulatory support are limited and well-defined guidelines for TPE in thyroid storm have not been established.
Clinical

Case:
A 41-year-old man with no past medical history presented with weight loss, diarrhea, and syncope. The patient was febrile (100.4°F), hypertensive (141/88 mmHg), and tachycardic with atrial fibrillation and rapid ventricular response of >200 beats per minute. He rapidly developed respiratory failure, requiring intubation. Laboratory evaluation showed free T4 (FT4) 20.8 ng/dL (0.8-1.8 ng/dL) and thyroid-stimulating hormone (TSH) < 0.01 mIU/L (0.5-5.0 mIU/L). Burch-Wartofsky score was 70. Echocardiogram demonstrated severe global cardiomyopathy with an ejection fraction (EF) of 6-10%. Patient was treated with beta-blockade, propylthiouracil (PTU), iodide, corticosteroids, and cholestyramine. He developed refractory cardiogenic shock and cardiac arrest, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with Impella left-ventricular unloading. Hepatic failure required PTU discontinuation and FT4 remained elevated. TPE was initiated on hospital days 3, 4, and 5 through the VA-ECMO circuit. Free T4 decreased from 5.15 to 2.58, 1.81, and 1.11 ng/dL, respectively, after sequential exchanges. Thyroid stimulating immunoglobulin (TSI) decreased from 9.24 to 2.56 to 1.73 IU/L (0-0.55 IU/L). EF improved to 31-35% and patient was decannulated from VA-ECMO. Hospital course was complicated by disseminated intravascular coagulation, renal failure requiring dialysis, and nosocomial infections. On hospital day 54, the patient developed asystole and expired.

Discussion:
TPE can rapidly reduce circulating thyroid hormone levels. Biochemical improvement may not always translate into clinical recovery once organ failure has developed. This case suggests that TPE may have greater clinical utility when used earlier in severe thyroid storm, rather than being limited to late rescue therapy. Given limited existing literature, more prospective research is needed to establish objective clinical criteria, such as degree of organ failure, Burch-Wartofsky score, or presence of cardiogenic shock requiring mechanical circulatory support, to identify patients with thyroid storm most likely to benefit from TPE earlier in their clinical course. Given the severity of cardiogenic shock and the temporal association of clinical deterioration with beta-blockade, the case also raises concern for beta-blockade in thyrotoxicosis. Currently no clear guidelines on how much beta-blockade is tolerable in patients with thyrotoxicosis and low EF to avoid cardiovascular collapse exist.

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