Rachel L. Singletary, DNP, AGACNP-BC: No financial relationships to disclose
Background: Thyroid storm is an endocrine emergency characterized by excessive thyroid hormone and multi-organ dysfunction.¹ Severe cases with cardiogenic shock carry high mortality.²,³,⁴,⁵ We present a case of cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of severe thyrotoxicosis. Successful treatment with plasmapheresis resulted in cardiac recovery.
Methods: A retrospective chart review was done to obtain all information for this case report. A 43-year-old previously healthy male presented with progressive dyspnea, chest pain, abdominal distension, and bilateral lower extremity edema. On admission, he was hypotensive and in atrial fibrillation with rapid ventricular response (~190 bpm). Laboratory studies revealed TSH < 0.01mIU/L, free T4 5.11ng/dL, and the Burch-Wartofsky score was 55, consistent with thyroid storm. Imaging demonstrated anasarca and bilateral pleural effusions. Initial management included propranolol, Lugol’s iodine, methimazole, hydrocortisone, and cholestyramine. Antithyroid agents were intermittently held due to transaminitis and hyperbilirubinemia. Despite therapy, he developed pulseless electrical activity (PEA) arrest with return of spontaneous circulation after 5 minutes. Right heart catheterization revealed elevated filling pressures (RA 27 mmHg, PCWP 26 mmHg) and low cardiac index (1.44 L/min/m²). Intra-aortic balloon pump (IABP), Impella 5.5, and ultimately VA-ECMO were instituted for biventricular failure. The patient underwent six sessions of plasmapheresis for thyroid hormone removal, a recognized adjunctive therapy in severe thyroid storm refractory to medical management.⁵ Lithium was also added as an alternative thyroid-suppressive agent.
Outcome: Complications included acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT), disseminated intravascular coagulation (DIC), ischemic colitis, and groin wound infection with candidemia after ECMO decannulation. He was treated with micafungin and broad-spectrum antibiotics, along with wound VAC therapy. He was successfully decannulated from VA-ECMO after 11 days of support with Impella removal 13 days later. Following extubation and renal recovery, he demonstrated progressive multi-organ improvement. Once the patient was off all mechanical and renal support and clinically stable, GDMT was initiated and he was progressed with rehabilitation. He underwent a total thyroidectomy for definitive treatment and ultimately was discharged to inpatient rehabilitation on hospital day 62. This case illustrates a fulminant thyroid storm complicated by cardiogenic shock, cardiac arrest, and multi-organ failure, successfully managed with advanced mechanical circulatory support and plasmapheresis. VA-ECMO and Impella have been reported as lifesaving bridge therapies in severe thyrotoxic cardiomyopathy.⁴ Plasmapheresis effectively lowers circulating thyroid hormones and provides stabilization when conventional pharmacologic therapy is contraindicated.⁵ Early multidisciplinary coordination among endocrinology, cardiology, cardiac surgery, nephrology, and critical care teams was critical for survival.
Conclusion: Fulminant thyroid storm can progress rapidly to refractory cardiogenic shock and multi-organ failure. Prompt recognition, early hemodynamic support, and adjunctive plasmapheresis can be lifesaving bridge strategies to definitive therapy such as thyroidectomy. A multidisciplinary, individualized approach is essential for optimal outcomes.
