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Valverde Márquez Á, Mories Álvarez MT, Villanueva Alvarado HS, Vivas Vaca XC, Delgado Gómez M. Fighting thyrotoxicosis with therapeutic plasma exchange: A case report. ENDOCRINOL DIAB NUTR 2024; 71:177-180. [PMID: 38735679 DOI: 10.1016/j.endien.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 05/14/2024]
Abstract
Thyrotoxicosis is the clinical condition resulting from an excess of thyroid hormones for any reason. The main causes are Graves-Basedow disease, toxic multinodular goitre and toxic adenoma. The medical treatment to control thyroid function includes antithyroid drugs, beta blockers, iodine solutions, corticosteroids and cholestyramine. Although therapeutic plasma exchange is not generally part of the therapy, it is an alternative as a preliminary stage before the definitive treatment. This procedure makes it possible to eliminate T4, T3, TSI, cytokines and amiodarone. In most cases, more than one cycle is necessary, either daily or every three days, until clinical improvement is observed. The effect on thyrotoxicosis is temporary, with an approximate duration of 24-48h. This approach has been proposed as a safe and effective alternative when the medical treatment is contraindicated or not effective, and when there is multiple organ failure or emergency surgery is required.
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Affiliation(s)
| | | | | | | | - Manuel Delgado Gómez
- Endocrinology and Nutrition Department, Salamanca University Healthcare Complex, Spain
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Ocon AJ, Rosenblum M, Desemone J, Blinkhorn R. Severe cholestatic hyperbilirubinaemia secondary to thyrotoxicosis complicated with bile cast nephropathy treated with plasma exchange and haemodialysis. BMJ Case Rep 2019; 12:12/6/e229097. [PMID: 31171533 DOI: 10.1136/bcr-2018-229097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thyrotoxicosis rarely presents as cholestatic hyperbilirubinaemia, and severe bilirubin elevation may lead to bile cast nephropathy. We present a case of a young woman with newly diagnosed Graves' disease with thyrotoxicosis who developed severe hyperbilirubinaemia and bile cast nephropathy. Serial plasma exchange and temporary haemodialysis led to full renal recovery. After treatment of her thyrotoxicosis with antithyroid medication and radioactive iodine ablation, her bilirubin normalised.
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Affiliation(s)
- Anthony J Ocon
- Internal Medicine, Albany Medical College, Albany, New York, USA
| | | | - James Desemone
- Internal Medicine, Division Endocrinology, Albany Medical College, Albany, New York, USA
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Ba JH, Wu BQ, Wang YH, Shi YF. Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure: A case report. World J Clin Cases 2019; 7:500-507. [PMID: 30842962 PMCID: PMC6397818 DOI: 10.12998/wjcc.v7.i4.500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/21/2018] [Accepted: 12/30/2018] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Jun-Hui Ba
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Ben-Quan Wu
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Yan-Hong Wang
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Yun-Feng Shi
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
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Simsir IY, Ozdemir M, Duman S, Erdogan M, Donmez A, Ozgen AG. Therapeutic plasmapheresis in thyrotoxic patients. Endocrine 2018; 62:144-148. [PMID: 29968224 DOI: 10.1007/s12020-018-1661-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/23/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Ilgin Yildirim Simsir
- Ege University Medical Faculty, Division of Endocrinology and Metabolism Disorders, Izmir, Turkey.
| | - Murat Ozdemir
- Department of General Surgery, Ege University Medical Faculty, Izmir, Turkey
| | - Soner Duman
- Department of Internal Medicine, Ege University Medical Faculty, Izmir, Turkey
| | - Mehmet Erdogan
- Ege University Medical Faculty, Division of Hematology, Izmir, Turkey
| | - Ayhan Donmez
- Ege University Medical Faculty, Division of Hematology, Izmir, Turkey
| | - Ahmet Gokhan Ozgen
- Ege University Medical Faculty, Division of Endocrinology and Metabolism Disorders, Izmir, Turkey
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Linardi A, Michou E, Ilias I, Petychaki F, Kakoulidis I, Pappa A, Koukkou E. Resistant Thyrotoxicosis due to Graves' Disease in Pregnancy: Case Report and Review of the Literature. Cureus 2018; 10:e3232. [PMID: 30410838 PMCID: PMC6207494 DOI: 10.7759/cureus.3232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The effective management of Graves' disease (GD) during pregnancy is crucial for maternal and neonatal well-being. Conventional treatment of GD during pregnancy includes antithyroid drugs (ATDs) and surgery, ideally during the second trimester. We report a 27-year-old woman with GD and we present the course of GD during her three consecutive pregnancies. During the first pregnancy, thyrotoxicosis was successfully treated with low doses of antithyroid drugs; in the second pregnancy, thyrotoxicosis was only controlled at the third trimester; while in the third pregnancy, our patient presented with treatment-resistant thyrotoxicosis, which was finally managed with corticosteroids in adjunction with ATDs. Although hyperthyroid, the patient maintained her fertility. Resistance to ATD is a rare condition and in our case was adequately controlled with corticosteroids.
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Affiliation(s)
- Anastasia Linardi
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens, GRC
| | - Ekaterini Michou
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens, GRC
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens, GRC
| | - Foteini Petychaki
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens , GRC
| | - Ioannis Kakoulidis
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens, GRC
| | - Athina Pappa
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens, GRC
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, E. Venizelou Hospital, Athens, GRC
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Garla V, Kovvuru K, Ahuja S, Palabindala V, Malhotra B, Abdul Salim S. Severe Hyperthyroidism Complicated by Agranulocytosis Treated with Therapeutic Plasma Exchange: Case Report and Review of the Literature. Case Rep Endocrinol 2018; 2018:4135940. [PMID: 29552362 PMCID: PMC5818894 DOI: 10.1155/2018/4135940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/17/2017] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Vishnu Garla
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Karthik Kovvuru
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Shradha Ahuja
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Bharat Malhotra
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sohail Abdul Salim
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Zhang Q, Guan Y, Xiang T, Liu S, Chen Q, Zhang Q. COMBINATION OF MOLECULAR ADSORBENT RECIRCULATING SYSTEM AND RADIOIODINE FOR THE TREATMENT OF CONCURRENT HYPERTHYROIDISM AND SEVERE LIVER DYSFUNCTION: A RETROSPECTIVE COHORT STUDY. Endocr Pract 2016; 23:141-148. [PMID: 27819764 DOI: 10.4158/ep161417.or] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The treatment of hyperthyroidism associated with severe liver dysfunction (LD) is a clinical challenge, and there has been no unified examination of this problem. The objective of this study was to assess the efficacy and safety of radioiodine (131I) in combination with a molecular adsorbent recirculating system (MARS) for the treatment of hyperthyroidism complicated by severe liver LD. METHODS A total of 116 hyperthyroidism patients with concomitant LD who received MARS treatment were studied retrospectively. The patients were grouped according to whether or not they also received 131I treatment: Group 1 (59 patients) received 131I following MARS treatment, while Group 2 (57 cases) received only MARS. Clinical outcomes, including thyroid hormone levels, liver function parameters, and therapeutic efficacy were calculated. RESULTS The overall response rate was significantly greater in Group 1 than in Group 2 (P<.01). The clinical indicators improved significantly in both groups 3 months after treatment compared with before treatment (P<.05), but Group 1 showed a greater improvement. Compared with Group 1, patients in Group 2 had a longer stay in hospital (P<.05), and received more frequent MARS treatments (P<.05). CONCLUSION The combination of MARS and 131I for the treatment of hyperthyroidism complicated by severe LD was effective and safe. The use of this system could rapidly improve liver function and metabolism, allowing 131I therapy to be applied as early as possible with a shortened recovery time of liver function. ABBREVIATIONS ALSS = artificial liver support system ALT = alanine transaminase AST = aspartate transaminase ATD = antithyroid drugs DBil = direct bilirubin FT3 = free tri-iodothyronine FT4 = free thyroxine 131I = radioiodine INR = international normalized ratio LD = liver dysfunction MARS = molecular adsorbent recirculating system MELD = model for end-stage liver disease PT = prothrombin time TBil = total bilirubin TSH = thyroid-stimulating hormone.
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Yoo WS, Chung HK. Recent Advances in Autoimmune Thyroid Diseases. Endocrinol Metab (Seoul) 2016; 31:379-385. [PMID: 27586448 PMCID: PMC5053048 DOI: 10.3803/enm.2016.31.3.379] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 07/06/2016] [Accepted: 07/13/2016] [Indexed: 12/13/2022] Open
Abstract
Autoimmune thyroid disease (AITD) includes hyperthyroid Graves disease, hypothyroid autoimmune thyroiditis, and subtle subclinical thyroid dysfunctions. AITD is caused by interactions between genetic and environmental predisposing factors and results in autoimmune deterioration. Data on polymorphisms in the AITD susceptibility genes, related environmental factors, and dysregulation of autoimmune processes have accumulated over time. Over the last decade, there has been progress in the clinical field of AITD with respect to the available diagnostic and therapeutic methods as well as clinical consensus. The updated clinical guidelines allow practitioners to identify the most reasonable and current approaches for proper management. In this review, we focus on recent advances in understanding the genetic and environmental pathogenic mechanisms underlying AITD and introduce the updated set of clinical guidelines for AITD management. We also discuss other aspects of the disease such as management of subclinical thyroid dysfunction, use of levothyroxine plus levotriiodothyronine in the treatment of autoimmune hypothyroidism, risk assessment of long-standing antithyroid drug therapy in recurrent Graves' hyperthyroidism, and future research needs.
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Affiliation(s)
- Won Sang Yoo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Hyun Kyung Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea.
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