Effectiveness of preoperative plasmapheresis in a pregnancy complicated by hyperthyroidism and anti-thyroid drug-associated angioedema

Advances in the differential diagnosis of transient hyperthyroidism in pregnancy and Graves' disease

BACKGROUND

The occurrence of thyrotoxicosis during pregnancy is mainly attributed to gestational transient thyrotoxicosis (GTT) and Graves' disease (GD). It is important to distinguish between GTT and Graves' disease because the two diseases are treated very differently. However, a gold standard for the differential diagnosis of the two diseases is currently lacking, and the most common method of differentiation is based on past medical history and clinical presentation combined with thyroid-related antibodies.

METHODS

A literature search of the electronic databases PubMed, Embase, Medline, Google Scholar, Cochrane Library, China Knowledge Infrastructure, Wanfang Database, Chinese Scientific Journals Full Text Database and China Biomedical CD-ROM was performed. The search period ranged from journal inception until 2022. We used the following search terms in "All fields": {["thyroid" (common field) OR "thyroid" (subject line)] OR "hyperthyroidism" (common field)} AND {["pregnancy" (title) OR "pregnancy" (title)] AND "one over" (common field)} OR {["pregnancy" (common field) OR "pregnancy" (common field) OR "pregnancy" (subject line)] AND "Graves'" (common field)}.

RESULTS

In recent years, some clinical studies at home and abroad have proposed other meaningful differential indicators, such as thyroid stimulating hormone, chorionic gonadotropin, thyroid hormone levels and thyroid ultrasound.

CONCLUSION

The differential diagnostic significance of each of these indicators is summarised here with the goal of providing a better reference for the differential diagnosis of hyperthyroidism during pregnancy in clinical practice.

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.

THERAPEUTIC PLASMA EXCHANGE AS A BRIDGE TO TOTAL THYROIDECTOMY IN PATIENTS WITH SEVERE THYROTOXICOSIS

Objective

Graves disease is the most common cause of thyrotoxicosis. Medical management is the first-line treatment but may be contraindicated or ineffective. In patients with severe, refractory thyrotoxicosis therapeutic plasma exchange (TPE) may be indicated as a bridge to thyroidectomy.

Methods

We present 3 cases of thyrotoxicosis refractory to medical management that were successfully treated with TPE and subsequent total thyroidectomy, and provide an analysis of the response to therapy via a change in free thyroxine (fT4) levels throughout their treatment course.

Results

The average change in fT4 per liter of fluid exchanged was 0.37 ng/dL (SD = 0.08) and the average percentage change of fT4 after each treatment was 20.7% (SD = 8.28). The mean decrease in fT4 after 4 TPE treatments was 57.4%. All patients successfully underwent total thyroidectomy without complication and were discharged from the hospital.

Conclusion

TPE should be considered for thyrotoxic patients with severe hyperthyroidism or thyroid storm refractory to medical management or contraindications to antithyroid drugs who need a bridge to total thyroidectomy. In these cases, TPE was a safe and effective treatment that enabled definitive management with thyroidectomy and may be considered in other patients with severe refractory hyperthyroidism or thyrotoxicosis.

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.

Therapeutic apheresis in pregnancy: General considerations and current practice

It is widely known that pregnancy does not represent a contraindication to therapeutic apheresis (TA) techniques. In fact, since the first experiences of TA in pregnancy for the prevention of hemolytic disease of the newborn, several diseases are at present treated with TA, mainly within 6 clinical categories: (a) TA is a priority and has no alternative equally effective treatment (e.g., thrombotic thrombocytopenic purpura); (b) TA is a priority but there are alternative therapies not contraindicated in pregnancy (e.g., myasthenia gravis); (c) TA is an effective tool of saving/avoiding drugs contraindicated in pregnancy (e.g., systemic lupus erythematosus); (d) TA is a treatment of specific conditions/complications of pregnancy with maternal and/or fetal risk (e.g., antiphospholipid syndrome); (e) TA is a treatment of specific conditions of pregnancy with exclusive fetal risk (e.g., hemolytic disease of the newborn); (f) TA is a treatment of disease which is strongly indicated and can exceptionally occur during pregnancy (e.g., Goodpasture's syndrome). When dealing with TA pregnant patients, some technical aspects due to the physiological changes of gestation have to be carefully considered, in particular the increase of the circulating blood volume. Moreover a multidisciplinary medical team, including an obstetrician, a clinical consultant, specialist in TA and in transfusion medicine, and a neonatologist stand as a basic requirement for the proper management of some clinical conditions that may be characterized by high maternal and fetal risk.