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.
Lithium ; Thyroid Crisis ; Plasmapheresis