PMC8417732_01
Timeline of key clinical events. T4, thyroxine; T3, tri-iodothyronine; TSH, thyroid-stimulating hormone; NG, nasogastric; IV, intravenous; PTU, propylthiouracil; NaI, sodium iodide; VA-ECMO, veno-arterial extra-corporeal membrane oxygenation; CRRT, continuous renal replacement therapy; TPE, therapeutic plasma exchange; MMZ, methimazole.
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f1
Thyroid function test, sent as part of investigations for myocarditis, showed thyrotoxicosis with an elevated serum free thyroxine (FT4) level of 42.1pmol/L (reference range: 8.0-16.0pmol/L) and a suppressed serum thyroid stimulating hormone (TSH) at <0.01mIU/L (reference range: 0.45-4.50mIU/L) (Figure 1) - our patient had thyroid storm complicated by thyrocardiac disease, with a Burch-Wartofsky score of 105. Treatment was promptly initiated with nasogastric propylthiouracil, intravenous sodium iodide and hydrocortisone (Figure 1). We decided to institute TPE; with the first cycle performed on day 2 of admission, with 2.5L of albumin and 0.5L of saline (Figure 1). After the first cycle, his vasopressor support reduced significantly (only requiring low dose noradrenaline infusion) and his tri-iodothyronine (T3) levels improved (Figure 1).
Concurrent CRRT, VA-ECMO and TPE. O2, oxygen, CO2, carbon dioxide, others as per Figure 1.
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f2
He remained persistently hypotensive with maximal dual vasopressor support, and was initiated on VA-ECMO support (Figure 2).