Synergistic Use of Plasmapheresis and Lithium in Refractory Thyroid Storm
https://doi.org/10.15605/jafes.041.S1
- Author:
Humaira Nuraqilah Mohd Yusof
1
;
Nur Aini Eddy Warman
1
;
Nur Haziqah Baharum
1
;
Aimi Fadilah Mohamad
1
;
Mohd Hazriq Awang
1
;
Fatimah Zaherah Mohamed Shah
1
;
Rohana Abdul Ghani
1
Author Information
1. Department of Internal Medicine, Faculty of Medicine, Universiti Teknologi MARA
- Publication Type:Journal Article
- MeSH:
Lithium;
Thyroid Crisis;
Plasmapheresis
- From:
Journal of the ASEAN Federation of Endocrine Societies
2026;41(S1):118-
- CountryPhilippines
- Language:English
-
Abstract:
Introduction:Thyroid storm is a life-threatening endocrine emergency
with a mortality rate of 8–25% despite optimal therapy.
Some patients exhibit a refractory phenotype characterized
by rapid clinical deterioration and failure of conventional
treatment, necessitating early escalation. Therapeutic
plasmapheresis and lithium represent adjunctive therapies
targeting different aspects of thyroid hormone physiology,
yet their combined use remains underexplored.
Case:A 55-year-old male with Graves’ disease, non-adherent to
treatment since 2020, presented with fever, palpitations,
and dyspnea for 2 days. He recently started on carbimazole
30 mg daily and propranolol 1 week prior. On examination,
blood pressure was 158/74 mmHg, heart rate 180 bpm,
Glasgow Coma Scale 15/15 with bibasal crepitations.
Electrocardiogram showed atrial fibrillation at 168 bpm.
His Burch-Wartofsky score was 95, consistent with thyroid
storm. Standard therapy with propylthiouracil 250 mg QID,
Lugol’s iodine, intravenous hydrocortisone 100 mg TDS,
and carvedilol was commenced. However, after 3 days of
treatment, he developed acute confusion and persistent
fast atrial fibrillation requiring cardioversion. Liver
function remained normal. Plasmapheresis was initiated
on day 4 for six sessions. Propylthiouracil was switched to
methimazole due to a declining white cell count from (5.5–
3.2 ×10⁹/L). Lithium 300 mg BD was added on day 13 due to
inadequate free thyroxine 4 (FT4) reduction. After 1 week
of combined therapy, FT4 decreased from 70 to 35 pmol/L.
Conclusion:Early recognition of refractory disease and timely escalation
are critical as refractory thyroid storm carries high
mortality, especially with cardiovascular and neurological
involvement. When conventional therapy fails, plasmapheresis facilitates rapid clearance of circulating thyroid
hormones and inflammatory mediators, while lithium
inhibits thyroid hormone release, providing an alternative
mechanism when thionamides alone are insufficient. Their
combined use offers a synergistic approach and targets both
circulating and intrathyroidal hormone pools, suggesting
that early dual-modality intervention is essential to
overcome therapeutic resistance and improve overall
outcomes in refractory disease.
- Full text:2026080509422016679EP_A176.pdf
