McGonigle Andrea M, Tobian Aaron A R, Zink Jennifer L, King Karen E
Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Hemapheresis and Transfusion Support (HATS), Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
J Clin Apher. 2018 Feb;33(1):113-116. doi: 10.1002/jca.21560. Epub 2017 Jun 13.
Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8-2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8-1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.
甲状腺危象是甲状腺功能亢进症的一种潜在致命并发症，伴有甲状腺激素增加和甲状腺毒症症状加剧。一线治疗包括甲巯咪唑（MMI）或丙硫氧嘧啶（PTU），以阻断甲状腺激素的产生，作为通向确定性手术治疗的桥梁。未经治疗的甲状腺危象死亡率高达30%；当患者无法耐受或药物治疗失败，尤其是无法接受甲状腺切除术时，这一情况尤其令人担忧。治疗性血浆置换（TPE）是甲状腺危象的美国血液学会（ASFA）III类适应证，这意味着该疗法的最佳作用尚未确立，且文献中的病例数量有限。然而，TPE可以清除与白蛋白、自身抗体、儿茶酚胺和细胞因子结合的T3和T4，可能对这些患者有益。我们报告了一名甲状腺危象患者，他无法耐受PTU，随后MMI治疗失败，且不适合进行甲状腺切除术。因此，连续4天每天进行TPE（置换1.0个血浆容量，用5%白蛋白替代，并补充2单位血浆）。在治疗过程中，患者的甲状腺激素恢复正常，甲状腺危象症状基本缓解；他的T3从2.27降至0.81 ng/mL（正常范围0.8 - 2.0），T4从4.8降至1.7 ng/mL（0.8 - 1.8），心率恢复正常，精神状态改变得到改善，转为正常窦性心律。他最终以甲状腺功能正常的状态出院。他在TPE治疗过程中未出现副作用。当传统治疗不成功或不适用时，TPE是治疗甲状腺危象的一种安全有效的方法。
