Crash Landing of Thyroid Storm: A Case Report and Review of the Role of Extra-Corporeal Systems

Abstract

Thyroid storm is a rare but life-threatening endocrinological emergency with significant mortality ranging from 10-30% with multi-organ involvement and failure. In view of the rarity of this condition and efficacy of established first line medical treatment, use of extra-corporeal treatments are uncommon, not well-studied, and its available evidence exists only from case reports and case series. We describe a 28-year-old man who presented with an out-of-hospital cardiac arrest secondary to thyroid storm. Despite conventional first-line pharmacotherapy, he developed cardiogenic shock and circulatory collapse with intravenous esmolol infusion, as well as multi-organ failure. He required therapeutic plasma exchange, concurrent renal replacement therapy, and veno-arterial extra-corporeal membrane oxygenation, one of the few reported cases in the literature. While there was clinical stabilization and improvement in tri-iodothyronine levels on three extra-corporeal systems, he suffered irreversible hypoxic-ischemic brain injury. We reviewed the use of early therapeutic plasma exchange and extra-corporeal membrane oxygenation, as well as the development of other novel extra-corporeal modalities when conventional pharmacotherapy is unsuccessful or contraindicated. This case also highlights the complexities in the management of thyroid storm, calling for caution with beta-blockade use in thyrocardiac disease, with close monitoring and prompt organ support.

Keywords: continuous renal replacement therapy; extra-corporeal membrane oxygenation; multi-organ failure; out-of-hospital cardiac arrest; therapeutic plasma exchange; thyroid storm.

Figure 1

Timeline of key clinical events. T4, thyroxine; T3, tri-iodothyronine; TSH, thyroid-stimulating hormone; NG, nasogastric; IV, intravenous; PTU, propylthiouracil; NaI, sodium iodide; VA-ECMO, veno-arterial extra-corporeal membrane oxygenation; CRRT, continuous renal replacement therapy; TPE, therapeutic plasma exchange; MMZ, methimazole.

Figure 2

Concurrent CRRT, VA-ECMO and TPE. O₂, oxygen, CO₂, carbon dioxide, others as per Figure 1.