Plasmapheresis as an Effective Treatment for Thyroid Storm in Critical Patients: Case Reports and Systematic Literature Review

Abstract Background: Thyrotoxic crisis is a rare, multisystemic and lethal condition, especially when its reversal is delayed. The Burch Wartofsky score establishes severity and predicts the indication of plasmapheresis, but once there is organ dysfunction this therapy should be considered despite of the score. When it is added to conventional treatments it is really effective because of the quick clinical compensation of critically ill patients regardless of the main trigger factor of this emergency. Clinical Cases: 5 patients with thyrotoxic crisis, 1 man and 4 women that had Graves’disease (4 cases) or TSH-secreting tumor (1 case). The precipitating factors were: 1 case due to orchitis, 2 due to poor adhesion, 1 due to antithyroid drugs hepatoxicity and 1 due to ketoacidosis. All them had elevated free T4 ranging from 3.38 to >7.77 ng/dL. All them had high Burch Wartofsky scores (55 to 70) and severe organ dysfunctions: 4 cases with hepatopathy (hepatosplenomegaly, jaundice and coagulopathy) and cardiopathy (diastolic dysfunction and pulmonary hypertension) and 1 case with severe diabetic ketoacidosis. Plasmapheresis (2 to 3 sessions were performed) were indicated for clinical compensation and so subsequent definitive treatment: 3 cases received radioiodine therapy and 1 case had total thyroidectomy. All of them progressed well. The patient who died had already severe prior comorbidities. We performed a systematic survey on PubMed of English articles (case reports and reviews) in humans and we analyzed our 5 cases along with the 108 articles about the use of plasmapheresis in thyroid storm from 1970 to 2020 and we compare them to 394 ones of conventional treatments in past 10 years. Our objective was to evidence plasmapheresis is not related to a higher mortality of patients who underwent to it. We found 7% of mortality in both groups. The chi square test showed an Odds Ratio of (CI 95%) = 1,091 reinforcing there is no relation between number of deaths and treatment type. Conclusion: Plasmapheresis is a therapeutic option with few reports in the literature and without clear guidelines about indication criteria or better timing to initiate it. The statistical analysis showed that 3 or more organ dysfunctions in thyroid storm are related to higher death rates. Its early employment within 24 hours of the initial symptoms and the prompt normalization of free T4 are related to lower mortality. It is a safe and effective therapy that allows thyroid storm patients to be compensated to receive definitive treatment with lower chances of death. Reference: Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan. Medicine (Baltimore). 2016;95(7):e2848.