Endocrine Abstracts

We describe the use of plasmapheresis for pre-operative stabilisation in a case of refractory Grave’s thyrotoxicosis. Our case is a 21 year woman with 12 month history of severe Grave’s disease. Her serum freeT4 was >100 pmol/L (ref.range 11–24) and TSH <0.014 mU/L at diagnosis, had no goitre and negative thyroid peroxidase antibodies. Thyroid uptake scan confirmed Grave’s disease. She was treated with carbimazole 60 mg daily and propranolol. She remained symptomatic with freeT4 of 56.5 pmol/L, was switched to propylthiouracil (PTU) 400 mg twice daily, later increased to thrice daily. She remained symptomatic, required hospital admission for collapse, was given pulsed methyl prednisolone, prednisolone 40 mg daily and Lugol’s iodine. She was electively admitted to intensive care unit for pre-operative stabilisation. She received 4 hours of plasmapheresis prior to surgery and intravenous esmolol infusion. Serum TSH was <0.014, free T4- 27.3, free T3- 13.2 (ref.range 4.0-6.8 pmol/L)before plasmapheresis and TSH 0.35, freeT4- 14.3, freeT3- 3.5 after plasmapheresis. She underwent total thyroidectomy without any peri-operative complications and remains well on replacement doses of levothyroxine at followup. Thyroidectomy is the treatment of choice for refractory thyrotoxicosis when response to medical therapy was suboptimal. However surgery in patients with resistant thyrotoxicosis is fraught with dangers including cardiovascular instability, therefore careful preoperative stabilisation of hyperthyroidism is essential for optimal outcome. Plasmapheresis is rarely used in preoperative stabilisation, though it is relatively a safe procedure with rapid improvement in thyroid hormone levels. Therefore it should be considered earlier in the pre-operative management of severe thyrotoxicosis if medical therapy fails. This case highlights the difficulties in medical management of resistant thyrotoxicosis and the beneficial role of preoperative plasmapheresis. Reference: 1. Ezer et al. “Preoperative Therapeutic Plasma Exchange in Patients With Thyrotoxicosis” Journal of Clinical Apheresis 2009; 24:111–114.

Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.