SESSION TITLE: What's New in the ICU
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Severe thyrotoxicosis in patients with gastrointestinal disturbances is associated with elevated mortality since standard therapy to lower thyroid hormone levels is ineffective. We present a different treatment modality used for treatment of thyroid storm.
CASE PRESENTATION: A 27 year old woman at 21 weeks gestational age and history of untreated hyperthyroidism presented to the hospital with new onset atrial fibrillation and vaginal bleeding. Pelvic ultrasound was performed that revealed intra-uterine fetal demise that required dilation and evacuation. The patient’s thyroid function panel showed severe thyrotoxicosis (Thyroid stimulating Hormone <0.008 µIU/mL, Free T3 12.3pg/ml, Free T4 4.43 ng/dl). She was hemodynamically unstable with atrial fibrillation with fast ventricular response and was admitted to the intensive care unit for management. The clinical course was complicated with septic shock, secondary to community acquired pneumonia, and respiratory failure requiring endotracheal intubation. She also developed a significant ileus, acute kidney injury, and ischemic hepatitis making the standard oral treatment for thyrotoxicosis ineffective. She received intravenous steroids , beta blockers and antibiotcs but her condition failed to improve. The patient was started on charcoal hemodialysis followed by plasmapheresis as a rescue therapy that had been previously described in rare case. Thyroid function testing and her clinical condition began to improve. The patient was successfully extubated after five days of initiation of charcoal hemodyalisis.
DISCUSSION: Treatment of thyrotoxicosis in patients unable to take oral medications should focus on normalization of thyroid hormone levels utilizing conventional medical therapy (1). Plasmapheresis is an effective alternative but reduces circulating thyroid hormone levels within 3 days (1). Charcoal hemodialysis is another option that is usually employed in the setting of intoxication with a drug or poison that can be removed at a rate that exceeds endogenous elimination by the liver or kidney (2). The use of this type of hemodialysis for thyroid storm has only been reported in case reports showing a faster decrease in thyroid hormone levels compared to plasmapheresis (3).
CONCLUSIONS: We present this case to show alternative treatment strategies for thyroid storm when patients do not respond to standard therapy and are clinically unstable to tolerate thyroidectomy.
Reference #1: Alfadhli E, Gianoukakis AG. Management of severe thyrotoxicosis when gastrointestinal tract is compromised.Thyroid.2011. Mar;21(3).215-20.
Reference #2: Ghannoum M, Gosselin S. Enhanced poison elimination in critical care. Adv Chronic Kidney Dis. 2013 Jan;20(1):94-101.
Reference #3: Herrmann J, Rudorff KH, Gockenjan G, Konigshausen T, Grabensee B, Kruskemper HL. Charcoal haemoperfuison in thyroid storm. Lancet.1977 Jan 29;1(805):428.
DISCLOSURE: The following authors have nothing to disclose: Hiram Rivas-Perez, Eric Adkins
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