Graves' disease (GD) is an autoimmune condition affecting the thyroid gland. The aim of treating GD is to control the symptoms of
hyperthyroidism and achieve long-term remission.
Antithyroid drugs (ATDs) are the medications of choice among newly-diagnosed GD patients as they are easy to be delivered and cause remission in more than 50% of patients. However, ATDs increase the risk of hepatotoxicity, especially among patients with liver abnormalities. Patients who cannot tolerate ATDs should receive definitive
therapy such as radioactive
iodine (RAI) or surgery. In order to minimize the risk of
thyroid storm during these procedures, patients should be in euthyroid condition and receive bridging
therapy. Therapeutic
plasma exchange (TPE), which aims to remove
thyroid hormones from plasma, is one of the modalities that can be considered as a bridging
therapy during the
perioperative period among GD patients who cannot tolerate ATD.
Case Presentation: A 35-year-old man with general weakness and
thyrotoxicosis symptoms was admitted to the emergency room. Lid retraction, diffuse
Goiter, and
tremors were evident. Laboratory findings revealed TSH = 0.005 µIU/mL, FT4 = 7.77 ng/dL, TRAb = 9.90 IU/L, ALT = 123 U/L, total
bilirubin = 23.94 µmol/L, and direct
bilirubin = 10.26 µmol/L. Ultrasonographic examination showed the enlargement of the thyroid gland, and abdomen ultrasonographic evaluation showed mild
hepatomegaly with mild fatty infiltration. The patient was diagnosed with GD, suspected
thyroid storm, elevated liver
transaminases, and
fatty liver disease. The patient then received
methimazole,
propranolol, and
glycyrrhizin. During observation, the patient developed
drug-induced liver injury (DILI) evidenced by an increase in liver
enzymes (ALT up to 1023 U/L) and the elevation of total
bilirubin to 258.21 µmol/L, so
methimazole was stopped. After discontinuing
methimazole, liver injury improved. However,
thyrotoxicosis symptoms returned, so the patient underwent a total
thyroidectomy. In order to achieve a euthyroid status before surgery, five sessions of therapeutic
plasma exchange were performed, which improved the signs and symptoms of
hyperthyroidism and retained the
thyroxine hormone within the normal range.
Thyroidectomy was then performed successfully without serious complications (e.g.,
thyroid storm, etc.).
Conclusions: