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

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.

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.

Weathering the storm: A case of thyroid storm refractory to conventional treatment benefiting from therapeutic plasma exchange

Thyroid storm is a severe manifestation of thyrotoxicosis characterized by systemic organ dysfunction secondary to a hypermetabolic state. Although antithyroid drugs, steroids, beta-blockers, antipyretics, and cholestyramine are the standard of care, some patients inadequately respond to these conventional therapies. Therapeutic plasma exchange has been previously utilized as a treatment modality in patients with a poor response to routine therapies or with contraindications to them. Herein, we report our experience with the management of a case of thyroid storm refractory to conventional treatment but responsive to therapeutic plasma exchange.