Amiodarone induced thyrotoxicosis may not respond to therapeutic plasma exchange like patients with graves' disease: A report of two cases and literature review

Abstract

The achievement of euthyroid state has been suggested in patients with thyrotoxicosis undergoing surgery to reduce the risk of thyroid storm. However, euthyroid state could not always be achieved by antithyroid drugs. Therefore, therapeutic plasma exchange (TPE) is an option in this condition. A 58-year-old male patient with a history of type-2 diabetes using 200 mg amiodarone per day, admitted for diabetic ketoacidosis (DKA), induced by thyrotoxicosis. with palpitation, sweating, polyuria, and polydipsia. Euthyroid state could not be achieved, despite all apropriate treatments for thyrotoxicosis. Therefore, preparation with TPE followed by total thyroidectomy was planned. A 35% decrease in fT3 (free T3) and fT4 (free T4) levels were achieved, after two sessions of TPE. A 74-year-old male patient, admitted for acute anterior myocardial infarction (AMI) induced by thyrotoxicosis due to Graves’ disease. Multiple vessel disease was detected on primer percutanous coronary angiography, and an emergency coronary artery bypass grafting (CABG) was planned. Therefore, preperation with TPE was planned before surgery. A substential decrease in fT4 and fT3 levels (45% and 72%, respectively) levels were achieved, after one session of TPE. Most of the studies evaluating the efficacy of TPE in patients with thyrotoxicosis are including patients with Graves’ disease and toxic multinodular goiter, and TPE was indicated as an effective option for preparation of these patients for surgery. However, as presented in case 1, TPE may not be effective in amiodarone induced thyrotoxicosis (AIT) as in cases with thyrotoxicosis due to Graves’ disease.