Background: Thyroid storm is a rare manifestation of a common endocrine condition. Plasma exchange is increasingly recognised as a bridge to total thyroidectomy for refractory thyrotoxicosis.
We present a case of a 59 year-old male who was in fulminant thyroxtoxicosis. He described a four day history of palpitations and peripheral oedema. On examination he had new onset atrial fibrillation, congestive heart failure and Graves’ orbitopathy. Biochemistry showed TSH <0.05 mU/L (0.3 – 4.5), T4 73 pmol/L (7.0 – 17), T3 39 pmol/L (3.5 – 6.0), TSH receptor antibody 70 IU/L (<1.8).
Shortly during admission, he had fluctuating altered level of consciousness, requiring an intensive care admission for intubation and sedation. Burch-wartofsky point scale was highly suggestive for thyroid storm at 50 points. Treatment for thyroid storm was commenced: carbimazole 20mg TDS, via nasogastric route (NG), propranolol 80mg TDS NG, cholestyramine 4g QID NG and intravenous hydrocortisone 100mg TDS. His ICU stay was complicated with ventilator associated pneumonia, difficulty weaning from ventilation, anaemia, thrombocytopaenia and further aspiration pneumonia and shock requiring vasopressor support. His echocardiogram demonstrated moderate global systolic dysfunction.
Due to limited improvement with maximal medical therapy, plasma exchange was given in three sessions with succeeding rapid clinical improvement in neurological status. Plasma exchange was used to bridge to total thyroidectomy and tracheostomy insertion day 25 of admission. He was rehabilitated to functional independent status after three months.
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