Therapeutic Plasma Exchange for Preoperative Stabilization in Graves’ Disease Complicated by Agranulocytosis
https://doi.org/10.15605/jafes.041.S1
- Author:
Muhammad Azim Puad
1
;
Nadia Nordin
1
;
Elliyyin Katiman
1
;
Hazwani Aziz
1
;
Hidayatil Alimi Keya Nordin
1
Author Information
1. Hospital Tengku Permaisuri Norashikin
- Publication Type:Journal Article
- MeSH:
Plasma Exchange;
Agranulocytosis;
Graves Disease
- From:
Journal of the ASEAN Federation of Endocrine Societies
2026;41(S1):149-
- CountryPhilippines
- Language:English
-
Abstract:
Introduction:Severe thyrotoxicosis is particularly difficult to manage
when antithyroid drugs are contraindicated. Therapeutic
plasma exchange (TPE) is an adjunctive option in
complicated hyperthyroidism, including thyroid storm
and refractory thyrotoxicosis, through the rapid removal of
circulating thyroid hormones, hormone-binding proteins,
cytokines, and thyroid autoantibodies. However, its
precise role and indications remain incompletely defined.
We report two patients with Graves’ disease complicated
by carbimazole-induced agranulocytosis in whom TPE was
used as bridging therapy before total thyroidectomy.
Cases:The first patient was a 32-year-old female who developed
carbimazole-induced agranulocytosis 1 month after
the diagnosis of hyperthyroidism. Biochemical control
remained unsatisfactory despite second-line therapy with
high-dose lithium, cholestyramine, propranolol, corticosteroids, and 5 days of Lugol’s iodine. Over 8 days, free
thyroxine (fT4) increased by 13%, necessitating TPE for
preoperative stabilization. Following three cycles over 4
days, fT4 decreased by 20%, from 52 to 41 pmol/L, enabling
successful total thyroidectomy.
The second patient was a 26-year-old female who presented with neutropenic sepsis and severe agranulocytosis
2 months after being diagnosed with Graves’ disease. She
received second-line therapy, and neutrophil recovery
occurred only after 7 days of granulocyte colony-stimulating
factor. TPE, together with Lugol’s iodine, was then initiated
as bridging therapy before surgery. After 5 days of Lugol’s
iodine and three TPE cycles, fT4 decreased by 43%, from
58 to 33 pmol/L, permitting total thyroidectomy.
Conclusion:These cases highlight TPE as a useful bridging strategy
in Graves’ thyrotoxicosis when antithyroid drugs are
precluded by agranulocytosis, and conventional secondline therapy fails to achieve adequate biochemical control.
TPE may facilitate timely stabilization and safe progression to definitive surgical treatment.
- Full text:2026081017522072520EP_S003.pdf
