Use of Plasmapheresis and Cholestyramine in the Management of Thyroid Storm in the Setting of Cardiogenic Shock and Elevated Liver Enzymes: A Case Report and Review of Literature

Background: Thyroid storm is a rare, life-threatening endocrine emergency, and management becomes particularly challenging in patients with concurrent cardiac and hepatic dysfunction when standard antithyroid therapy is contraindicated. The objective of this report is to describe a patient with thyroid storm complicated by cardiogenic shock and liver injury who was successfully treated using alternative hormone-lowering strategies. Case Report: A 55-year-old woman with severe ischemic cardiomyopathy presented with syncope and was found to have severe thyrotoxicosis following exposure to amiodarone. Laboratory evaluation revealed a thyroid-stimulating hormone level below 0.01 milli-international units per liter (reference range 0.49-4.67) and a free thyroxine level greater than 7.8 ng per deciliter (reference range 0.61-1.6). She developed encephalopathy, acute kidney injury, and marked liver injury. Despite these findings, blood pressure remained within the normal range. Invasive hemodynamic assessment confirmed cardiogenic shock. Antithyroid medications were withheld because of hepatic dysfunction. Management included corticosteroids, cholestyramine, supportive care, and 3 sessions of plasmapheresis. Following 3 sessions of plasmapheresis, she showed marked biochemical and clinical improvement, with normalization of liver function and recovery of renal function, allowing successful discharge. Discussion: This case illustrates the diagnostic difficulty of thyroid storm in patients with advanced heart failure and preserved blood pressure and adds to the limited literature on alternative treatment strategies in the setting of organ dysfunction. Conclusion: This case demonstrates that plasmapheresis combined with cholestyramine may be effective in stabilizing patients with severe thyroid storm when conventional antithyroid therapies cannot be used and highlights the need for heightened clinical suspicion in atypical presentations.