Thyroid Storm With Multiorgan System Failure: Use of Therapeutic Plasma Exchange to Address a Treatment Conundrum.

Background/Objective: Thyroid storm is a life-threatening condition characterized by clinical signs and symptoms of hyperthyroidism and decompensation of one or more organ systems. Our objective was to report a rare therapeutic challenge encountered in managing a patient with multiorgan failure due to thyroid storm, where usual treatment options were contraindicated, and therapeutic plasma exchange (TPE) was required prior to therapy with thyroidectomy. Case Report: A 54-year-old man hospitalized for nausea and vomiting was found to have severe thyrotoxicosis with concern for thyroid storm. He was initially started on the appropriate treatment, which included stress-dose steroids, a thionamide, and a beta-blocker. However, due to the severity of his hyperthyroidism, the patient's clinical condition deteriorated. He developed acute liver failure, acute congestive heart failure, and acute respiratory failure requiring mechanical ventilation. Due to his multiorgan system failure, treatment options were limited. He thus underwent TPE with rapid improvement in his clinical condition and was able to undergo successful thyroidectomy. Discussion: TPE has been shown to effectively improve severe thyrotoxicosis, when other treatment options are contraindicated, to allow patients to safely receive definitive treatment for hyperthyroidism. Conclusion: This case underscores the importance of promptly recognizing the complications of thyroid storm that can result in the inability to tolerate thionamides and other treatment modalities. TPE can be a life-saving treatment option in the appropriate setting. We stress the importance of the timely recognition of when TPE should be used and when to consider the prompt transfer of a patient to a facility where TPE can be facilitated.