Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

Total Thyroidectomy while on Extracorporeal Membrane Oxygenation for Thyroid Storm

Thyroid storm is an acute life-threatening condition of hyperthyroidism that can present with cardiac failure, requiring extracorporeal membrane oxygenation (ECMO). We present the first case reported of total thyroidectomy successfully performed while on ECMO for thyroid storm in a 32-year-old male. This case highlights the challenges of managing refractory thyroid storm with multi-organ failure. We demonstrate that total thyroidectomy may still be safely performed while on ECMO for thyroid storm, if steps are taken to optimise the patient perioperatively, with careful surgical and anaesthesia planning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04430-9.

The Use of Plasmapheresis in a Severe Case of Amiodarone-Induced Thyrotoxicosis

Amiodarone-induced thyrotoxicosis (AIT) can be difficult to treat since amiodarone's long half-life leads to a persistent effect on thyroid function. We present a case of a 74-year-old male with severe AIT who presented with altered mentation and ultimately required intubation and intensive care for management of thyroid storm. Standard medical therapy for treatment of thyroid storm was initiated immediately, but the patient remained unresponsive with worsening biochemical parameters with increasing total T3 levels and sustained elevated levels of free T4 after 5 days of medical management. Due to the lack of a clinical and biochemical response to conventional medical therapy, the patient was started on plasmapheresis and underwent a total of 7 cycles of plasmapheresis over a period of 10 days. He significantly improved with plasmapheresis and was successfully bridged to a total thyroidectomy, which was completed without complications.

Therapeutic plasma exchange for Graves' disease in pregnancy

Graves' disease in pregnancy may be associated with maternal, fetal and neonatal complications, which are proportionate to the severity of hyperthyroidism. Optimal management is detailed preconception counselling, achievement of an euthyroid state prior to conception, and close monitoring of thyroid function and thyroid-stimulating antibodies together with judicious use of anti-thyroid medications during pregnancy. A case of Graves' disease in pregnancy, complicated by pancytopenia, with a deterioration in thyroid function following cessation of thionamide therapy is described here. Therapeutic plasma exchange was subsequently used to achieve rapid control prior to thyroidectomy. Therapeutic plasma exchange is an effective treatment for hyperthyroidism where thionamides are ineffective or contraindicated, as a bridge to definitive management.

Therapeutic plasma exchange in hyperthyroidism prior to surgery

PURPOSE

Therapeutic plasma exchange (TPE) is a treatment option to reduce thyroid hormones in the event of contraindication or unresponsiveness to antithyroid drugs (ATDs).

METHODS

We analyzed 11 patients with hyperthyroidism who received TPE prior to surgery between January 2008 and December 2016 at our center.

RESULTS

In total, 41 processes were applied to 11 patients with hyperthyroidism. The median age was 40 years, and 90.9% of the patients were female. Seven patients had Graves' disease, while four had a toxic multinodular goiter. The distribution of TPE indications comprised contraindication to ATDs (64%) and insufficient response to ATDs (36%). An adequate response was not obtained with TPE in two patients, and cholestyramine plus methimazole and Lugol solution were applied. The median number of TPE sessions was 3. During the TPE period, a β-blocker was applied concurrently except in one patient who was contraindicated for the drug. The reduction in FT3 and FT4 hormones and the increase in TSH levels were statistically significant after TPE application (p values of 0.003, 0.033 and 0.008, respectively). Regarding adverse events of TPE application, an allergic reaction was seen in one patient, while prolongation of prothrombin time without any clinical findings was seen in another patient. Ten patients underwent total thyroidectomy, and one patient underwent a gynecological surgery procedure without any major complications.

CONCLUSION

The American Society for Apheresis guideline, which is the most referenced guideline, mentions the utilization of TPE before thyroid surgery, only in patients with thyrotoxicosis despite the wider necessity of this treatment choice under the condition of uncontrolled hyperthyroidism prior to any kind of surgery. We concluded that TPE is a reliable and effective application in patients with hyperthyroidism before any surgical procedure, according to our study results.

Efficacy of preoperative therapeutic plasma exchange in patients with hyperthyroidism and factors affecting the number of sessions

PURPOSE

Achieving preoperative euthyroidism in patients with hyperthyroidism for whom antithyroid drugs (ATDs) cannot be used for treatment is a serious clinical problem. We aimed to evaluate the effectiveness of therapeutic plasma exchange (TPE) in hyperthyroid patients scheduled for surgery and predictive factors for a high number of TPE sessions.

METHODS

We retrospectively analyzed the data of 21 patients with hyperthyroidism who were treated with TPE for preoperative euthyroidism in our institution. Pre- and post-TPE thyroid function tests were compared to assess efficacy. Binary logistic regression analysis was applied to determine predictors of patients requiring a high number of TPE sessions.

RESULTS

All patients (20 patients with Graves' disease and 1 patient with toxic multinodular goiter; 12 women and 9 men; mean age 35.71 ± 12.38 years) had severe hyperthyroidism before TPE. The changes before and after TPE in fT3, fT4, and TSH levels were statistically significant (p < 0.001, p < 0.001, p = 0.002, respectively). The median number of TPE sessions was 8 (range: 1-24). Levels of fT3 before TPE were significantly higher in patients for whom higher numbers of TPE sessions were required (≥8) (OR: 1.427, 95% CI: 1.038-1.961, p = 0.028). Receiver operating characteristic curve analysis revealed an optimum cut-off value of 12.8 pg/ml for fT3 before TPE (91% sensitivity, 80% specificity, area under the curve: 0.927).

CONCLUSION

TPE should be considered as an effective alternative treatment option that can be used to rapidly achieve euthyroidism before surgery when ATDs cannot be used. Pre-TPE fT3 levels of >12.8 pg/ml may be an independent factor predicting the need for higher numbers of TPE sessions (≥8).

Therapeutic plasmapheresis for the treatment of thyrotoxicosis: A retrospective multi-center study

BACKGROUND AND AIMS

Thyroid storm and severe thyrotoxicosis remain among the most frequent endocrine emergencies, and first-line hyperthyroidism treatment is not always an option. Since the first report in 1970, plasmapheresis is a second-line treatment for severe or otherwise untreatable thyrotoxicosis when rapid euthyroidism is desired.

METHODS

We present a retrospective study of the experience in treating thyrotoxicosis with plasmapheresis between 2012 and 2020 in two specialized centers in Colombia. We register the demographic and clinical characteristic and compare the thyroid hormones and other biochemical measurements before and after treatment.

RESULTS

Data from 19 patients was obtained, 58% female with a median age of 35 years (IQR 23.5), and most of them with Graves' disease. The most frequent indication for plasmapheresis was thyroid storm. A median of 4 (IQR 2) sessions lead to a significant reduction in FT4 (P .0001) and TT3 (P < .0003) with a nonsignificant decrease in beta-blocker (P .7353) dose, no change in hepatic enzymes, and no adverse events. After plasmapheresis, thyroidectomy was performed in 10 patients.

CONCLUSIONS

Plasmapheresis is an effective and safe treatment option for reducing circulating thyroid hormones in severe thyrotoxicosis when other forms of treatment are contraindicated or in case of urgent thyroid and non-thyroid surgery. It is limited by its cost and the need for highly specialized resources.

Preoperative Therapeutic Plasma Exchange and Surgical Treatment in Thyrotoxicosis Patients: A Single-Centre Retrospective Cohort Study

Context

Therapeutic plasma exchange (TPE) provides time for thyroidectomy in thyrotoxic patients.

Objective

TPE is indicated in cases where antithyroid medications cannot be used due to the side effects or attain no adequate hormonal suppression response at the highest dosage and in cases of rapid onset of clinical symptoms. This study presents the treatment results of patients who underwent TPE and were subsequently operated for thyrotoxicosis.

Design

The patients who underwent thyroidectomy and TPE between January 1999 and February 2019 were retrospectively analyzed.

Subjects and Methods

The files of 27 patients with thyrotoxicosis who performed TPE prior to surgery were analyzed in relation to the demographic and clinical features.

Results

We included 15 (55.6%) females, 12 (44.4%) males with a mean age of 44 (23-82) years. The pre-TPE mean free thyroxine (fT4) level was 12 (5-46) pmol/L while free tri-iodothyronine (fT3) level was 34 (17-141) pmol/L. The post-TPE fT4 level was 6 (3-10) pmol/L while the fT3 level was 21 (12-41). There was one case of an allergic reaction during the procedure. In the postoperative follow-up, there was transient hypocalcemia in 8 (29%) patients, permanent hypocalcemia in 1 (3.7%) patient, and surgical site infection in 1 (3.7%) patient.

Conclusion

Preoperative TPE is an alternative treatment option for thyrotoxic patients. This is an especially effective treatment for patients with inadequate response or adverse reaction to antithyroid drugs or patients who need urgent surgery for thyroid storm.

Preoperative plasmapheresis in patients with Graves' disease intolerant to antithyroid drugs

Antithyroid drugs (ATDs) are the mainstay of treatment for Graves' disease with possible detrimental adverse effects. Surgery or radioactive iodine (RAI) ablation is the second choice among the treatment options in cases of non-remission. Normalization of serum thyroid hormone levels as much as possible is required before surgery or RAI to prevent thyrotoxic crisis in patients with uncontrolled Graves' disease. In recent decades, therapeutic plasma exchange (TPE) has been used in the treatment of thyroid storm, drug-induced hepatotoxicity and agranulocytosis, or patients with hyperthyroidism scheduled for emergency surgery. TPE is an effective method to reduce serum FT3, FT4, and TRAB levels in severe hyperthyroid conditions. Although TPE-related complications are rare, the risk of bleeding needs to be taken into consideration in patients who were scheduled for surgery within 24 h after TPE. In terms of reducing intraoperative bleeding, patients can be referred to surgery 24-48 h after TPE, or fresh frozen plasma transfusion can be the preferred treatment for emergency cases.

Therapeutic Plasma Exchange in Refractory Hyperthyroidism

INTRODUCTION

Hyperthyroid patients who are unresponsive to medical treatment remain a challenging clinical problem.

OBJECTIVE

The goal of our study was to evaluate the use of therapeutic plasma exchange (TPE) in hyperthyroid patients and their outcome after TPE.

METHOD

We retrospectively reviewed 22 patients who underwent TPE for refractory thyrotoxicosis in our institution: 13 with Graves' disease, 7 with amiodarone-induced thyrotoxicosis (AIT), 1 with toxic goiter, and 1 pregnant patient with familial nonautoimmune thyrotoxicosis.

RESULTS

Before TPE, all patients had severe hyperthyroidism, and antithyroid drugs were either contraindicated or not sufficiently effective to restore euthyroidism promptly. After all the TPEs, free T₄ (fT4) decreased significantly by 48% (p = 0.001) and fT3 by 52% (p = 0.0001). The median number of TPE sessions per patient was 4 (range: 1-10). There were no complications during the 91 TPE sessions. Total thyroidectomy with no severe side effects was performed on 16/22 patients and 1 other patient was treated with radioactive iodine. One patient died from severe thyrotoxicosis during medical care. The remaining 4 patients were followed up without any radical treatment. For all 7 patients with AIT, iterative TPE led to a significant clinical improvement, and amiodarone was continued for 1 patient. Available treatments were continued between TPE sessions (cholestyramine for 13 patients [60%] and glucocorticoids for 16 patients [73%]).

CONCLUSION

TPE allowed a safe decrease of 50% in thyroid hormone levels, and it should be considered for refractory hyperthyroid patients when medical treatments are contraindicated or have failed to restore euthyroidism, irrespective of the etiology of the thyrotoxicosis.

Therapeutic Plasma Exchange in the Critically Ill Patient: Technology and Indications

Therapeutic plasma exchange (TPE) is frequently the most common Apheresis Medicine technique used for extracorporeal therapy of a wide variety of renal, neurological, hematological, and other clinical indications. Many of these clinical indications require intensive care during critical illness. Conventional TPE uses one of two main technical methods to achieve the goal of removing known disease mediators from the plasma: using centrifugal forces to separate and remove components of blood, or a membrane filtration method that separates plasma from the cellular components of blood. The following review discusses the basic principles of TPE, the technological aspects, and relevant clinical scenarios encountered in the intensive care unit, including relevant guidelines and recommendations from the American Society for Apheresis.

Therapeutic plasma exchange with albumin as a valuable method of preparing thyrotoxic patients for a life-saving thyroidectomy

Hyperthyroidism affects approximately 1.2% of the population and its routine treatment includes antithyroid drugs (ATDs), radioiodine and surgery. Management of patients with resistance or contraindications to ATDs who require thyroidectomy may be challenging. We present the experience of our department in preparing thyrotoxic patients for life-saving thyroidectomy by using therapeutic plasma exchange (TPE) with albumin: one patient with Graves' disease and previous history of agranulocytosis and cholestatic jaundice after ATDs and two patients with amiodarone-induced thyrotoxicosis. Five to six TPEs were applied to each patient resulting in a decrease of fT3 by 57% to 83%, fT4 by 21% to 60% and decrease/normalization of total thyroid hormones. All patients underwent surgery successfully. In case of drug-resistant thyrotoxicosis or contraindications to ATDs, TPE can be a valuable tool in preparing patients for surgery. Albumin used as a replacement fluid appears to be effective in ameliorating clinical and laboratory symptoms of thyrotoxicosis.

Usefulness of plasmapheresis in patients with severe complicated thyrotoxicosis

The standard treatment of complicated thyrotoxicosis and thyroid storm with the concomitant use of antithyroid medication, iodine, beta-blockers, and corticosteroids is successful in most cases. However, treatment options are limited when antithyroidal drugs cannot be used or in cases that are refractory to standard treatment. Plasmapheresis provides a safe and effective strategy when initial treatment fails, facilitating the transition to definitive treatments such as thyroidectomy. We present two adults with complicated thyrotoxicosis successfully treated with plasmapheresis as a bridge therapy to thyroidectomy or as an alternative to drug-induced toxicity.

Therapeutic plasma exchange for control of thyroid storm

Therapeutic plasma exchange (TPE) for thyroid storm has recently been upgraded to a category II indication after decades though its recommendation level still remains at Grade 2C according to the American Society for Apheresis (ASFA). In the absence of prospective randomized controlled trials due to the rarity of thyroid storm, retrospective data from case series continue to elevate the clinical evidence supporting TPE as a life-saving modality for complicated thyroid storm patients. We report three cases of life-threatening thyroid storm from Graves' disease rescued by TPE via rapid reduction in circulating thyroid hormones. Each patient underwent TPE when it was judged that other thyroid storm treatment options were futile or unsafe. The first patient received 4 cycles of TPE while the second patient received 9 cycles of TPE, and the third patient received 2 cycles of TPE with satisfactory clinical improvement. Plasma FT4 and TSH receptor antibody levels of the first case declined by 41.3% and >50% respectively right after the first round of TPE; plasma FT4 of the second patient dropped by up to 31.6% during the course of TPE; plasma FT4 and TSH receptor antibody of the third patient declined by 66% and 56.2% respectively after the first cycle of TPE. This demonstrates the safety, efficacy, and feasibility of TPE in thyroid storm especially when other therapeutic interventions are contraindicated. TPE operates via the elimination of serum proteins-bound thyroid hormones, thyroid autoantibodies, cytokines, and catecholamines in addition to increasing unsaturated binding sites for thyroid hormones.

Use of Adjunctive Therapy to Achieve Preoperative Euthyroidism in Graves' Disease: A Case Report

BACKGROUND Graves' disease is an autoimmune disease of the thyroid gland and it is considered the most common cause of hyperthyroidism. It is characterized by particular eye manifestations, skin changes, and pretibial myxedema in addition to the signs and symptoms of hyperthyroidism. Graves' disease can be diagnosed based on clinical presentation and low thyroid stimulating hormone (TSH) and elevated free T4 (FT4) levels. Presence of TSH receptor antibody (TRAb) in the serum confirms the diagnosis of Graves' disease. Imaging studies like radioactive iodine scan will show a high and diffuse uptake. Graves' disease can be managed with three different treatment modalities: antithyroid medications, radioactive iodine, or surgical removal of the thyroid gland. Whenever surgery is indicated, careful preoperative management to achieve euthyroidism is needed to optimize the surgical outcome. CASE REPORT This is a case of a 37-year-old Saudi male known to have Graves' disease for 2 years who presented to the endocrine surgery clinic with neck swelling, difficulty breathing, and change in voice. After multiple attempts to control his fluctuating thyroid levels, the team eventually managed to achieve a euthyroid state in the patient with the addition of saturated solution of potassium iodide (SSKI), and thus rendering him eligible for urgent surgery. CONCLUSIONS We report this case to show that SSKI can be used as adjunctive therapy to achieve a preoperative euthyroid state in refractory Graves' disease.

Sepsis and thyroid storm in a patient with methimazole-induced agranulocytosis

Paediatric hyperthyroidism cases are mostly caused by Grave's disease. Thyroid storm is a life-threatening condition seen rarely, in severe thyrotoxicosis, occurring in about 1%-2% of patients with hyperthyroidism. Antithyroid medications and beta-blockers are typically the first-line management of thyroid storm. We report a challenging case of a 15-year-old girl who presented with thyroid storm in the setting of septic shock and methimazole-induced agranulocytosis. Since the first-line agents were contraindicated, plasmapheresis was used to control the thyroid storm and as a bridging therapy to the definitive therapy of early thyroidectomy. This is the first paediatric case report that outlines the use of plasmapheresis in the management of complicated thyrotoxicosis in a setting of septic shock.

Preoperative plasmapheresis experience in Graves' disease patients with anti-thyroid drug-induced hepatotoxicity

Hepatotoxicity is a rare but serious side effect of antithyroid drug (ATI) therapy in Graves' disease patients. Cessation of ATI drug is needed in most of the patients if liver enzymes highly elevated or in case of agranulocytosis. Permanent therapy, surgery or radioactive iodine ablation are the treatment choices to ensure euthyroidism in active Graves' disease patients. Therapeutic plasma exchange (TPE) can be an option to ensure euthyroidism, especially in patients scheduled for urgent surgery. In the present study, we present consecutive five cases of methimazole related severe hepatotoxicity that underwent TPE before thyroid surgery. The median number of apheresis sessions was 3 (range: 2-5). Free triiodothyronine (FT3) 65-83 %, free thyroxine (FT4) 22-66 %, thyrotropin receptor antibodies (TRAB) 55-96 % decreases were observed. All patients underwent total thyroidectomy. TPE is an effective method to reduce serum FT3, FT4, TRAB levels in the short term to provide better thyroid hormone status before urgent surgery in ATI induced toxic hepatitis patients.

Effect of Plasma Exchange in Thyroid Storm With Consideration of Its Distribution Into the Extravascular Space

Plasma exchange (PE), which directly removes some plasma thyroid hormones, is a treatment option for thyroid storm. However, the effect of PE has not been accurately assessed yet. Here we assessed the effect of PE in a patient with thyroid storm while taking into consideration the distribution of thyroid hormones in the extravascular space. A 51-year-old woman with thyroid storm underwent 2 PE procedures at our hospital. By measuring changes in thyroid hormone levels in plasma, fresh frozen plasma (FFP) used, and waste fluid during each 2.5-hour PE procedure, we calculated the efficiency of thyroid hormone removal based on the hypothesis that total thyroid hormone content before and after PE is the same. During the patient’s first PE procedure, the estimated thyroxine (T₄) balance in the extravascular space (ΔX) was −70 μg, which corresponds to approximately 19% of T4 in the waste fluid. During the second PE procedure, ΔX was −131 μg, which corresponds to approximately 52% of T4 in the waste fluid. These data indicated that the source of removed T4 during PE varies. The amount of T₄ removed from the extravascular space should be taken into account during assessment of the effect of PE in thyroid storm.

The role of therapeutic plasmapheresis in patients with hyperthyroidism

BACKGROUND

Hyperthyroidism is characterized by excess hormone secretion from the thyroid gland. Anti-thyroid drugs (ATDs), surgery, and radioactive iodine can be used in treatment. Plasmapheresis is a rapid and effective treatment option in cases where rapid euthyroidism is needed to be obtained due to complications of thyrotoxicosis and major adverse effects of ATDs.

MATERIAL AND METHOD

We present patients receiving plasmapheresis to provide immediate euthyroidism due to severe hyperthyroidism, adverse effects of ATDs, or non-thyroid surgery from January 2012 to December 2016.

RESULTS

This study included 18 patients. The etiology of hyperthyroidism was TDG in seven patients, TDMNG in two, TA in two, TMNG in four, and one patient had AIT. Plasmapheresis was performed to achieve euthyroidism before surgery in two patients. The mean plasmapheresis session was 5.35. The mean number of sessions needed for patients with TDG and TDMNG was 4, whereas it was 6.5 for patients with TA and TMNG (p = 0.07). The decrease of mean free thyroxine and free triiodothyronine were 57 % and 73 %, respectively (p < 0.001). After plasmapheresis, total thyroidectomy was performed in 14 patients. Euthyroidism was achieved with RAI in one patient and with medical therapy in three patients.

CONCLUSIONS

Plasmapheresis therapy is a reliable and effective treatment option for patients who cannot use ATDs because of their adverse events and those with hyperthyroidism that does not resolve with these drugs, or to achieve euthyroidism before total thyroidectomy, RAI or non-thyroid emergency surgery. However, it cannot be used widely because it is expensive and invasive.

Management of Cardiogenic Shock due to Thyrotoxicosis: A Systematic Literature Review

Background

A grave complication of thyrotoxicosis, or thyroid storm, is the development of heart failure and cardiomyopathy. Recognizing this condition is imperative in preventing further left ventricular dysfunction and cardiogenic shock. This manuscript aims to review the literature on cardiogenic shock associated with thyrotoxicosis and present management recommendations on this rare condition.

Methods

A literature search was performed in December of 2018, using the PubMed medical search engine. A systematic search was carried out using the keywords Thyroid Storm AND Cardiogenic Shock and Thyrotoxicosis AND Shock.

Management

Decrease of thyroid hormone levels using therapeutic plasma exchange LV Unloading and ventilation by Impella and Extracorporeal Mechanical Ventilation (ECMO).

Conclusion

Patients presenting with thyroid storm-induced shock may not be suitable candidates for traditional management with β-adrenergic blockers (β-blockers). The use of β-blockers could exasperate their condition. Through extensive literature review on this rare condition, the most effective management was found to be therapeutic plasma exchange in order to decrease thyroid hormone levels, which have direct toxic effect on the heart. Furthermore, the use of ECMO and Impella is advised to reduce pressure on the heart and ensure the patient’s organs are well oxygenated and perfused while the left ventricle is recovering.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Thyroid Storm with Multiorgan Failure Treated with Plasmapheresis

Background

Thyroid storm is a severe manifestation of thyrotoxicosis and can present with multiorgan failure. First line treatment of thyroid storm is directed towards decreasing thyroid hormone production and peripheral conversion of T4 to T3, and treating adrenergic symptoms. When medical therapy fails, plasmapheresis is an alternative treatment option. Here we present a patient with thyroid storm and multiorgan failure who was treated with plasmapheresis.

Case

A 50-year-old male with a history of hyperthyroidism, hypertension, and congestive heart failure presented to another hospital with fever and altered mentation. He was found to have pneumonia on imaging and was started on antibiotics. He developed shock complicated by atrial fibrillation with rapid ventricular rate which was treated with amiodarone. He was transferred to our hospital for further management. On arrival, TSH was <0.01 mIU/L, free T4 was >7 ng/dL and total T3 was 358 ng/dL. The endocrinology team determined he was in thyroid storm. His medical treatment of thyroid storm was aggressively titrated to maximal therapy. His hospital course was complicated by transaminitis, respiratory failure requiring intubation, shock requiring vasopressor support, kidney failure requiring continuous renal replacement therapy, and heart failure. Despite maximal anti-thyroid therapy, he had not improved clinically and T4 and T3 remained markedly elevated. A 4-day course of plasmapheresis was initiated resulting in marked lowering of T4 and T3 and clinical stability.

Conclusion

While current guidelines for plasmapheresis for thyroid storm recommend individualized decision making, no further clarification is provided on who would be a good candidate for the procedure. We present a patient with thyroid storm and multiorgan failure who was treated with plasmapheresis after failing maximal medical therapy. Given the significant improvement seen with plasmapheresis, endocrinologists should consider this mode of treatment earlier in the course of thyroid storm when patients are not improving with medical therapy alone.

Plasma exchange and early thyroidectomy in thyroid storm requiring extracorporeal membrane oxygenation

Thyroid storm with multi-organ failure limits the use of conventional treatment. A 44-year-old male presented with thyroid storm and experienced cardiovascular collapse after beta-blocker administration, with resultant fulminant multi-organ failure requiring inotropic support, mechanical ventilation, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy. Hepatic and renal failure precluded the use of conventional thyroid storm treatment and early plasma exchange was instituted. The patient underwent emergency thyroidectomy after four effective exchanges, with subsequent rapid reversal of multi-organ failure. The challenges of institution of plasma exchanges with ongoing ECMO support, dialysis and timing of thyroidectomy are discussed. This case highlights the important role of early therapeutic plasma exchange (TPE) as an effective salvage therapy for lowering circulating hormones and stabilization of patients in preparation for emergency thyroidectomy in patients with thyroid storm and fulminant multi-organ failure.

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

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 plasmapheresis in thyrotoxic patients

PURPOSE

For the treatment of thyrotoxicosis, alternative treatment modalities may be necessary if anti-thyroid drugs cannot be used due to side effects, inefficiencies, or there is a need to start a rapid action such as thyroid storm. By using therapeutic plasma exchange (TPE), it is possible to effectively and rapidly remove the increased thyroid hormones. We evaluated our results and experience on a rapid, effective, and reliable alternative treatment modality in thyrotoxic patients.

METHODS

TPE was performed in 46 thyrotoxic patients at the Adult Therapeutic Apheresis Center.

RESULTS

Forty six patients with a median age of 30 years (interquartile range [IQR] 30-50) were assessed. In 40 (87%) of the cases, the diagnosis was Graves' disease. The other causes of thyrotoxicosis were amiodarone-induced thyrotoxicosis (n = 4) and toxic nodular goiter (n = 2). The median and IQR of fT3 values in patients before TPE were 9.9 (6.5-16.8) pg/mL (N: 2.3-4.2) and the median and IQR of fT4 values were 2.9 (2.3-4.1) ng/dL (N: 0.74-1.52). When the procedure was terminated, the median and IQR of fT3 values in patients were 4.0 (3.1-5.2) pg/mL and the median and IQR fT4 values were 1.6 (1.4-2.0) ng/dL. The decrease in both free thyroid hormones was found to be statistically significant (p < 0.000).

CONCLUSION

Our study is the largest series of TPE in the literature used for thyrotoxicosis. In the light of the literature and our results, we conclude that TPE is an effective alternative treatment option to prepare for ablative treatment for cases that have side effects or ineffectiveness of anti-thyroid drugs.

[Challenges in the management of amiodarone-induced thyrotoxicosis]

Amiodarone, a benzofuranic iodine-rich pan antiarrhythmic drug, is frequently associated with thyroid dysfunction. This side effect is heterogeneous and unpredicted, motivating regular evaluation of thyroid function tests. In contrary to hypothyroidism, amiodarone-induced thyrotoxicosis (AIT) is a challenging situation owing to the risk of deterioration of the general and cardiac status of such debilitating patients. Classically, AIT is either an iodine-induced thyrotoxicosis in patients with an abnormal thyroid (type I), or due to a subacute thyroiditis on a "healthy" thyroid (type II). Even if many studies tried to better identify the types of AIT, the diagnostic dilemma of type of AIT could be present, and many patients are treated by an association of antithyroid drugs (useful for type I AIT) with corticoids (useful for type II AIT). Being the main etiological factor in AIT, amiodarone is supposed to be stopped, but it could remain the only anti-arrhythmic option that is needed to be either continued or reintroduced to improve the cardiovascular survival. Recently, many studies demonstrated that amiodarone could be continued or reintroduced in patients with history of type II AIT. Nevertheless, in the other patients, amiodarone maintenance complicates the therapeutic response to the antithyroid drugs and increases the risk of AIT recurrence. Thus, amiodarone therapy is preferred to be interrupted. In such patients, thyroid ablation is recommended once AIT is under control.

Issues in amiodarone-induced thyrotoxicosis: Update and review of the literature

Amiodarone, a benzofuranic iodine-rich pan-anti-arrhythmic drug, induces amiodarone-induced thyrotoxicosis (AIT) in 7-15% of patients. AIT is a major issue due to its typical severity and resistance to anti-thyroid measures, and to its negative impact on cardiac status. Classically, AIT is either an iodine-induced thyrotoxicosis in patients with abnormal thyroid (type 1), or due to acute thyroiditis in a "healthy" thyroid (type 2). Determination of the type of AIT is a diagnostic dilemma, as characteristics of both types may be present in some patients. As it is the main etiological factor in AIT, it is recommended that amiodarone treatment should be stopped; however, it may be the only anti-arrhythmic option, needing to be either continued or re-introduced to improve cardiovascular survival. Recently, a few studies demonstrated that amiodarone could be continued or re-introduced in patients with history of type-2 AIT. However, in the other patients, it is recommended that amiodarone treatment be interrupted, to improve response to thioamides and to alleviate the risk of AIT recurrence. In such patients, thyroidectomy is recommended once AIT is under control, allowing safe re-introduction of amiodarone.

Thyroid Storm Presenting as Psychosis

Thyroid storm is a life-threatening endocrine emergency with an incidence rate of 1% to 2%. It is a systemic condition of excessive thyroid hormone production and release leading to thermoregulatory, adrenergic, neuropsychiatric, cardiovascular, and abdominal manifestations. Although it is a rare condition, it carries a significant mortality rate. Hence, knowing the common and uncommon presentations of thyroid storm is important for its prompt diagnosis and treatment. In this article, we present an unusual case of a young woman who presented with psychosis as the manifesting symptom of thyroid storm. She did not respond adequately to conventional medical treatment, requiring plasmapheresis and a definitive thyroidectomy, which ultimately led to the return of patient’s baseline mental status and a dramatic recovery.

Diltiazem-Associated Cardiogenic Shock in Thyrotoxic Crisis

CLINICAL FEATURES

The patient we present is a 39-year-old woman with a history of hyperthyroidism who developed fast atrial fibrillation secondary to thyrotoxic storm. After the initiation of intravenous diltiazem drip, she developed hypotension, bradycardia, then asystole cardiac arrest.

THERAPEUTIC CHALLENGE

It is well known that calcium channel blockers and beta blockers should be used with extreme caution if the patient with thyroid storm has decompensated heart failure with reduced ejection fraction. Despite this, it is recognized that guidelines for the management of thyroid storm do not include an algorithm of action in this situation. Thus, dealing with low-output failure during thyroid storm may pose a critical challenge.

SOLUTION

A significant portion of patients with thyrotoxic storm have an underlying low-output cardiac failure. Early identification, proper hemodynamic monitoring, and administration of the agents with appropriate pharmacodynamic profile and therapeutic potentials are essential to avoid treatment-induced cardiogenic shock.

Severe Hyperthyroidism Complicated by Agranulocytosis Treated with Therapeutic Plasma Exchange: Case Report and Review of the Literature

AIM

To present a case of Graves' disease complicated by methimazole induced agranulocytosis treated with therapeutic plasma exchange (TPE) and review of the literature.

CASE PRESENTATION

A 21-year-old patient with a history of Graves' disease presented to the endocrine clinic. His history was significant for heat intolerance, weight loss, and tremors. Upon examination he had tachycardia, smooth goiter, thyroid bruit, and hyperactive reflexes. He was started on methimazole and metoprolol and thyroidectomy was to be done once his thyroid function tests normalized. On follow-up, the patient symptoms persisted. Complete blood count done showed a white blood cell count of 2100 (4000-11,000 cells/cu mm) with a neutrophil count of 400 cells/cu mm, consistent with neutropenia. He was admitted to the hospital and underwent 3 cycles of TPE and was also given filgrastim. He improved clinically and his thyroxine (T4) levels also came down. Thyroidectomy was done. He was discharged on levothyroxine for postsurgical hypothyroidism.

CONCLUSION

Plasmapheresis may be useful in the treatment of hyperthyroidism. It works by removing protein bound hormones and also possibly inflammatory cytokines. Further studies are needed to clarify the role of various modalities of TPE in the treatment of hyperthyroidism.

Graves' Disease Thyrotoxicosis and Propylthiouracil Related Agranulocytosis Successfully Treated with Therapeutic Plasma Exchange and G-CSF Followed by Total Thyroidectomy

Antithyroid drugs can be a rare cause of agranulocytosis (0.5% of treated patients). Suspension of these drugs is mandatory in these patients and may result in worsening hyperthyroidism. We report the case of a 27-year-old woman who is 3 months post-partum, breastfeeding, and suffering with Graves’ disease hyperthyroidism treated first with methimazole and then with propylthiouracil due to a methimazole allergy. She was admitted for urosepsis and agranulocytosis. The patient was diagnosed with propylthiouracil related agranulocytosis, diffuse toxic goiter and thyro-gastric syndrome. Antithyroid drug therapy was stopped resulting in a worsening of thyrotoxicosis. Agranulocytosis was treated with 8 doses of G-CSF with full recovery. To rapidly restore euthyroidism and to perform a thyroidectomy, the patient received 6 therapeutic plasma exchange (TPE) procedures, to clear thyroid hormones and anti-TSH receptor antibodies from blood, resulting in a pre-surgical euthyroid state without antithyroid drug therapy. Two years after thyroidectomy, the patient is well under thyroid hormone replacement therapy with a normal granulocyte count.

Interferon alpha-induced non-immune thyrotoxicosis treated by plasmapheresis

Interferon-alpha (IFN-α) is an effective drug used for the treatment of chronic hepatitis C. So far its numerous side effects have been reported in the literature. It may be difficult to always put IFN-induced thyroid diseases into a single classic thyroid disease table. There are numerous atypical thyroid diseases due to IFN usage for hepatitis C virus. Herein, we present a case with a rare clinical table such as thyrotoxicosis observed following IFN-α therapy in a patient with euthyroid nodular thyroid without autoimmune thyroiditis findings and the use of therapeutic apheresis method for the treatment of disease.

Severe Thyrotoxicosis Secondary to Povidone-Iodine from Peritoneal Dialysis

A 73-year-old male on home peritoneal dialysis (PD) with recent diagnosis of atrial fibrillation presented with fatigue and dyspnea. Hyperthyroidism was diagnosed with TSH < 0.01 mIU/L and FT4 > 100 pmol/L. He had no personal or family history of thyroid disease. There had been no exposures to CT contrast, amiodarone, or iodine. Technetium thyroid scan showed diffusely decreased uptake. He was discharged with a presumptive diagnosis of thyroiditis. Three weeks later, he had deteriorated clinically. Possible iodine sources were again reviewed, and it was determined that povidone-iodine solution was used with each PD cycle. Methimazole 25 mg daily was initiated; however, he had difficulty tolerating the medication and continued to clinically deteriorate. He was readmitted to hospital where methimazole was restarted at 20 mg bid with high dose prednisone 25 mg and daily plasma exchange (PLEX) therapy. Biochemical improvement was observed with FT4 dropping to 48.5 pmol/L by day 10, but FT4 rebounded to 67.8 pmol/L after PLEX was discontinued. PLEX was restarted and thyroidectomy was performed. Pathology revealed nodular hyperplasia with no evidence of thyroiditis. Preoperative plasma iodine levels were greater than 5 times the upper limit of normal range. We hypothesize that the patient had underlying autonomous thyroid hormone production exacerbated by exogenous iodine exposure from a previously unreported PD-related source.

Perfect storm: Therapeutic plasma exchange for a patient with thyroid storm

Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8-2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8-1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.

Successful Pretreatment Using Plasma Exchange before Thyroidectomy in a Patient with Amiodarone-Induced Thyrotoxicosis

INTRODUCTION

Amiodarone, used for the management of tachyarrhythmias, is associated with both hypothyroidism and thyrotoxicosis. Total thyroidectomy is an effective procedure for promptly reducing circulating thyroid hormone levels. It has been proposed in patients who have severe amiodarone-induced thyrotoxicosis (AIT) or are refractory to medical therapy, or when such therapy is contraindicated. Therapeutic plasma exchange (TPE) may be considered as a pretreatment for restoring a euthyroid state preoperatively, thereby reducing a patient's symptoms and the potential perioperative risk associated with thyrotoxicosis.

CASE REPORT

We describe the case of a 62-year-old man with type 2 AIT who presented with severe unremitting thyrotoxicosis after 8 weeks of medical therapy with glucocorticosteroids, thiamazole, and potassium perchlorate. Given the severity of his presentation, a total thyroidectomy was indicated. TPE was performed preoperatively and was successful in rapidly restoring euthyroidism. This dramatically improved the patient's symptoms which had been suggestive of ischemic heart disease. Subsequently, the patient underwent total thyroidectomy under general anesthesia without any major complications.

CONCLUSION

TPE is successful in rapidly restoring a clinical and biochemical euthyroid state, and may be used to decrease the perioperative risks associated with thyroidectomy in patients with life-threatening thyrotoxicosis or in cases refractory to medical treatment.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

Thyroid storm is an endocrine emergency which is characterized by multiple organ failure due to severe thyrotoxicosis, often associated with triggering illnesses. Early suspicion, prompt diagnosis and intensive treatment will improve survival in thyroid storm patients. Because of its rarity and high mortality, prospective intervention studies for the treatment of thyroid storm are difficult to carry out. We, the Japan Thyroid Association and Japan Endocrine Society taskforce committee, previously developed new diagnostic criteria and conducted nationwide surveys for thyroid storm in Japan. Detailed analyses of clinical data from 356 patients revealed that the mortality in Japan was still high (∼11%) and that multiple organ failure and acute heart failure were common causes of death. In addition, multimodal treatment with antithyroid drugs, inorganic iodide, corticosteroids and beta-adrenergic antagonists has been suggested to improve mortality of these patients. Based on the evidence obtained by nationwide surveys and additional literature searches, we herein established clinical guidelines for the management of thyroid storm. The present guideline includes 15 recommendations for the treatment of thyrotoxicosis and organ failure in the central nervous system, cardiovascular system, and hepato-gastrointestinal tract, admission criteria for the intensive care unit, and prognostic evaluation. We also proposed preventive approaches to thyroid storm, roles of definitive therapy, and future prospective trial plans for the treatment of thyroid storm. We hope that this guideline will be useful for many physicians all over the world as well as in Japan in the management of thyroid storm and the improvement of its outcome.

Changes of Thyroid Hormones and Their Binding Proteins during Plasma Exchange for Polyneuropathy in a Patient with Substituted Hypothyroidism due to Hashimoto's Thyroiditis

BACKGROUND

Pharmacodynamic studies and data concerning adaptation of thyroid substitution in patients with substituted hypothyroidism during plasma exchange (PE) is not available.

CASE REPORT

We measured TSH, fT3 and fT4, total T4, thyroxin binding globulin (TBG), and albumin before and after 5 PE procedures in a 37-year-old women who underwent PE for a therapy-resistant polyneuropathy. Thyroxin was increased empirically by 8% resulting in a dose of 1.95 µg/kg per day.

RESULTS

Despite larger reductions of total T4 and TBG over a series of 5 PEs (40-50% from baseline), only small reductions of 8% in fT3 and fT4 concentrations were documented with a concomittant increase in TSH level. Changes of fT4, fT3, and TSH remained within normal range.

CONCLUSIONS

i) Despite a significant decrease in total thyroid hormone pool following PE, fT4, fT3, and TSH concentrations changed only slightly. ii) Based on this observation, a general increase in thyroid replacement therapy before PE cannot be recommended, but considered in case of a high normal TSH level.

Therapeutic Plasmapheresis Enabling Radioactive Iodine Treatment in a Patient with Thyrotoxicosis

Therapeutic plasma exchange (TPE) is one possible treatment for patients resistant to conventional antithyroid drugs or requiring urgent attention for thyrotoxicosis. We report a 35-yr-old man with thyrotoxicosis, ultimately attributed to Graves' disease in whom antithyroid drug used initially was soon discontinued, due to abnormal liver function, and replaced by Lugol's solution. Three weeks later, an escape phenomenon (to Lugol's solution) was apparent, so we performed TPE to control the thyrotoxicosis. Two courses of TPE by a centrifugal type machine resulted in diminished levels of thyroid hormone levels, which then rebounded after another two courses of membrane filtration type TPE. However, the patient could be treated with radioactive iodine therapy without any complications at present.

Acute psychosis in a pregnant patient with Graves' hyperthyroidism and anti-NMDA receptor encephalitis

A previously healthy 36-year-old woman presented with visual hallucinations and acute psychosis manifested predominantly as hypersexuality. Laboratory testing demonstrated elevated free thyroxine levels, suppressed thyroid-stimulating hormone levels and presence of thyroid-stimulating immunoglobulin and thyroid peroxidase (TPO) antibodies consistent with Graves' disease. Despite achieving biochemical euthyroidism, she remained profoundly hypersexual. She did not respond to additional treatment with antipsychotics and corticosteroids, prompting further evaluation. Cerebrospinal fluid analysis detected pleocytosis, elevated IgG, and presence of antibodies against anti-N-methyl-D-aspartate receptor (NMDAR), glutamic acid decarboxylase 65 and TPO. These results suggested a diagnosis of anti-NMDAR encephalitis. Prior to initiation of immunomodulator therapy, she was discovered to be pregnant with date of conception around the time of her original presentation. She received plasmapheresis with resolution of psychosis and decrease in free thyroxine levels. Graves' disease remitted during the remainder of the pregnancy but relapsed 5 months post partum. She has not had further neuropsychiatric symptoms.

Thyroid Storm

Thyroid storm, an endocrine emergency first described in 1926, remains a diagnostic and therapeutic challenge. No laboratory abnormalities are specific to thyroid storm, and the available scoring system is based on the clinical criteria. The exact mechanisms underlying the development of thyroid storm from uncomplicated hyperthyroidism are not well understood. A heightened response to thyroid hormone is often incriminated along with increased or abrupt availability of free hormones. Patients exhibit exaggerated signs and symptoms of hyperthyroidism and varying degrees of organ decompensation. Treatment should be initiated promptly targeting all steps of thyroid hormone formation, release, and action. Patients who fail medical therapy should be treated with therapeutic plasma exchange or thyroidectomy. The mortality of thyroid storm is currently reported at 10%. Patients who have survived thyroid storm should receive definite therapy for their underlying hyperthyroidism to avoid any recurrence of this potentially fatal condition.

Role of plasma exchange in autoimmune hyperthyroidism complicated by severe tiamazol-induced cholestatic jaundice

Therapeutic plasma exchange (TPE) is an alternative treatment for hyperthyroidism, resulting in a rapid decline in plasma thyroid hormones and anti-thyroid antibodies. TPE has also been used both in primary liver disease and in drug-induced cholestasis. Data on thyrotoxic patients with severe hepatic complications are scarce. Cholestasis induced by imidazol-derived anti-thyroid drugs is extremely rare. The use of TPE for treating this complication was not previously reported. We report the experience of one such patient with a favorable response to TPE. A 45-year-old male patient with Graves' disease, presented with severe jaundice and extremely high serum bilirubin levels due to hepatotoxicity induced by tiamazol. Through extensive investigation primary liver disease, including viral, metabolic, neoplastic and autoimmune disease, as a cause of cholestasis were all ruled out. The patient underwent total of 6 TPEs which in combination with low dose of glucocorticoids and standard supportive measures, resulted in normalization of thyroid hormones and normal liver function tests. TPE provided a safe, rapid and effective treatment of severe drug-induced cholestasis and auto immune hyperthyroidism. From this case we conclude that TPE should be considered as a valuable alternative therapeutic option in thyrotoxic patients with severe complications. Guidelines and indication criteria for TPE treatment in patients with hyperthyroidism are still lacking.