Endocrine Abstracts

Introduction: Due to the risk of thyroid storm, achievement of euthyroid state is necessary in patients with thyrotoxicosis undergoing surgery. However, euthyroid state could not be always achieved by antithyroid drugs. Therefore, therapeutic plasmapheresis (TPE) can be used for this purpose.

Case 1: A-58-year old male patient was admitted to emergency department with diabetic ketoacidosis (DKA) induced by amiodarone induced thyrotoxicosis (AIT). He had a history of Tip2 diabetes and ventricular arrhythmia which were treated with intensive insulin therapy and 200 mg amiodorone/day. His plasma glucose, arterial pH, serum TSH, fT3, fT4 and TRAb levels were 613 mg/dl, 7.19 log [H⁺], <0.005 mIU/ml (0.4–4), 5.47 pg/ml (1.57–5.3), 5.3 ng/dl (0.8–1.9), 5.3 U/l (0–14), respectively. After appropriate treatment for DKA, propronolol 80 mg/day, methimazole 40 mg/day and methylprednisolone 60 mg/day were started. However, fT4 levels increased to >7.7 ng/dl 3 weeks after treatment. Therefore, thyroidectomy and preparation with TPE was planned. TPE was performed with plasma exchange method by Spectra Optia Apheresis System and %5 albumin and isotonic saline were used for replacement of plasma. After two sessions, fT4 and fT3 levels decreased only to 5.15 ng/dl and 2.22 pg/ml, respectively, consistent with a 35% decrease. A thyroidectomy was performed without any complication.

Case 2: A 74-year-old male patient with acute antertior myocardial infarction (AMI) induced by Graves’ disease was admitted to emergency department. On biochemical analysis his serum TSH, fT3, fT4 and TRAb levels were <0.005 mlU/ml, 10.6 pg/ml, 4.5 ng/dl and 24 IU/l (0–14), respectively. Treatment with propranolol 80 mg/day, methimazole 40 mg/day and ten drops of lugol solution was started. A primer percutanous coronary anjiography revealed multiple vessel disease and an emergent coronary artery bypass grafting (CABG) was planned. So, a TPE was performed. After one session, fT4 and fT3 decreased to 2.48 ng/dl and 2.96 pg/ml, respectively, which were consistent with a 45% and 72% decrease in fT4 and fT3 levels. The patient underwent CABG surgery without any complication.

Conclusion: Although only one session of TPE was effective to achieve euthyroid state in a patient with Graves’ disease, euthyroid state coud not be achived after two sessions of TPE in a patient with AIT. So, the thyrotoxicosis in patients with AIT may not respond to TPE like patients with Graves’ disease.