MED5 Plasmapheresis in the preoperative management of a patient with severe hyperthyroidism. (Medicine).

MED5 PLASMAPHERESIS IN THE PREOPERATIVE MANAGEMENT OF A PATIENT WITH SEVERE HYPERTHYROIDISM. Cindy Codispoti, DO, Dennis P. Mong, MD, and Maureen K. Koops, MD. Brooke Army Medical Center, Fort Sam Houston, Tex.

Thyroid storm is an uncommon life-threatening complication of hyperthyroidism. Conventional therapy of thyroid storm is directed toward reducing production and release of thyroid hormone from the gland and inhibiting peripheral conversion of thyroxine (T4) to triiodothyronine (T3). Therapy involves aggressive use of beta-blockade, antithyroid medications, iodine, corticosteroids, lithium, as well as treatment of the initiating event. We report a case of a 38-year-old woman with severe hyperthyroidism and a history of thyroid storm, which developed after surgical debridement of a secondarily infected brown recluse spider bite of the upper extremity. The patient was given propranolol 200 mg every 4 hours, ipodate 500 mg twice daily, and lithium 300 mg three times daily. The patient had also been receiving propylthiouracil (PTU) but had hypothromboxinemia associated with a life-threatening coagulopathy requiring discontinuance of this medication. Definitive treatment with thyroidectomy was planned, but despite a ggressive medical therapy the patient remained a poor surgical candidate because of severe weakness, tremulousness, and a pulse rate of 120 to 130/mm. Her TSH remained undetectable, FT4 was >13 ng/dL (normal, .76 to 1.79 ng/dL), and a serum FT3 level was 34.8 pg/mL (normal, 1.9 to 5.0 pg/mL). Therapy with plasmapheresis was initiated. After an initial 2 L plasma volume apheresis, free serum thyroxine (FT4) was decreased by at least 40% and free serum triiodothyronine (FT4) was also decreased. Further decreases in serum FT4 and FT3 levels were obtained with two additional sessions and preoperatively, her serum FT4 level had been reduced by at least 55% and her FT3 level was in the normal range. She underwent successful thyroidectomy. Her operative course was uncomplicated. Plasmapheresis is a therapeutic procedure, which has been useful in the management of many diseases. To be effective, the solute being removed must be highly bound to proteins and have a small volume of distribution. Thyroid hormone is exten sively bound to plasma proteins, making the volume of distribution small and plasmapheresis a useful therapeutic modality. In addition to our case, there are several other reports of thyroid storm responding to therapy with plasmapheresis. Plasmapheresis should be considered in the management of thyroid storm or severe hyperthyroidism unresponsive to traditional therapy.