SUN-338 - Therapeutic Plasma Exchange for Refractory Thyroid Storm as A Bridge to Emergent Thyroidectomy

Background: Thyroid storm is a life-threatening escalation of thyrotoxicosis that can progress to cardiopulmonary collapse and multiorgan failure, particularly when standard therapies are limited by organ dysfunction.


Case Presentation: A 71-year-old woman with Graves’ disease presented with weakness and lethargy after missing methimazole 5 mg daily for over one week. The patient had thyrotoxicosis with thyroid stimulating hormone (TSH) < 0.10 (0.27- 4.2 ulU/mL), Free T4 >5.0 (0.9-1.8 ng/dL), total T3 369 (80-200 ng/dL), TSI 337 (0.00-0.55IU/L), and TSHRab >40 ( < 1.75IU/L). She was started on methimazole 10 mg daily but had rapid deterioration with organ dysfunction including flash pulmonary edema and acute liver injury with a Burch Wartofsky score of 50 consistent with thyroid storm, prompting intubation and multimodal management. The patient continued methimazole 10 mg daily along with IV hydrocortisone and Lugol’s solution. Lower dose of methimazole was used due to transaminitis. The patient had worsening transaminitis with AST 36 to 585 (4-32 U/L) and ALT 37 to 467 (4-33 U/L). Patient clinically did not improve despite 48 hours of maximal medical therapy. Given patient’s rapid deterioration, and contraindications to standard therapies due to transaminitis, therapeutic plasma exchange (TPE) was initiated to rapidly reduce circulating thyroid hormones, autoantibodies and protein-bound iodine. Following 3 sessions of TPE, over seven days, TFTs improved to Free T4 1.7 ng/dL, total T3 145 ng/dL, and the patient demonstrated significant clinical improvement. The patient also had improvement in LFTs with AST 26 U/L and ALT 23 U/L, allowing stabilization, extubation, and discharge to rehabilitation on methimazole 5mg daily.
The patient was readmitted 10 days after with a recurrent thyroid storm. She was started on methimazole, hydrocortisone, and Lugol’s solution but again developed transaminitis, restricting medical therapy. Given thyroid eye disease, RAI was deferred. Due to rapid relapse of thyrotoxicosis, a second course of TPE was used as a bridge to definitive surgical management. After clinical and biochemical improvement with 3 TPE sessions, the patient underwent emergent total thyroidectomy. Post-thyroidectomy, the patient's thyroid function normalized, and she was transitioned to stable thyroid hormone replacement, with no further episodes of thyroid storm.


Conclusion: The use of TPE in this case emphasizes its profound impact as a life-saving bridge therapy for recurrent thyroid storm, where traditional approaches are insufficient or contraindicated, as in this patient with acute liver injury. This case highlights early coordination for definitive thyroidectomy in the setting of recurrent storm and multiorgan failure. In this case, definitive surgical therapy, even with critical illness, was paramount for long-term survival and disease control.

*Unless otherwise noted, all abstracts presented at ENDO must not be released to the press or the public until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.*