Treatment of Severe Thyrotoxicosis With Therapeutic Plasma Exchange in a Patient With a Methimazole Adverse Reaction

Sep 28, 2026

Therapeutic plasma exchange (TPE) can control severe thyrotoxicosis, including thyroid storm, when conventional measures fail to control circulating thyroid hormone levels. The case describes a woman in her late 70s with atrial fibrillation, hypertension, hyperthyroidism, and anxiety who developed severe thyrotoxicosis after levothyroxine following hemorrhagic stroke and myocardial infarction. A methimazole adverse reaction limited standard therapy. Two TPE sessions stabilized her without thyroidectomy or radio-iodine ablation, enabling safe discharge.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

AccessFree to download

Introduction

Thyrotoxicosis and causes

Clinical manifestations and urgency

First-line antithyroid treatment

Role of therapeutic plasma exchange

Case description and management overview

Methimazole adverse reaction

TPE course and outcomes

Review began 10/05/2025 Review ended 11/24/2025 Published 12/02/2025 © Copyright 2025 Buryk et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98315 Open Access Case Report Treatment of Severe Thyrotoxicosis With Therapeutic Plasma Exchange in a Patient With a Methimazole Adverse Reaction Yaroslav Buryk 1, Concepcion Arteaga 2 , Leah E. Magdal 3, Joseph T. DiMarco 3, Olutomi T. Akinsete 3 1. Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Miami, USA 2. Critical Care, Jackson Health System, Miami, USA 3. Critical Care, American University of the Caribbean School of Medicine, Miami, USA Corresponding author: Joseph T. DiMarco, [joseph.t.dimarco@gmail.com](joseph.t.dimarco@gmail.com) Abstract Recent research indicates that therapeutic plasma exchange (TPE) has been successfully used in the treatment of thyrotoxicosis in patients where conventional treatment measures failed to effectively control severe thyrotoxicosis, also known as thyroid storm. We present the case of a woman in her late 70s with a history of atrial fibrillation (AFib), hypertension, hyperthyroidism, and anxiety, who presented to the hospital following a hemorrhagic stroke and myocardial infarction that subsequently developed severe thyrotoxicosis following the administration of levothyroxine. During her treatment course, the patient experienced an adverse reaction to methimazole, complicating management by precluding the use of conventional treatment protocols for severe thyrotoxicosis. TPE was successfully used to stabilize the patient over the course of two plasma exchanges without the need for thyroidectomy or radio-iodine ablation of the thyroid post stabilization, and was able to be safely discharged home. Categories: Therapeutics, Internal Medicine, Endocrinology/Diabetes/Metabolism Keywords: acute management of thyrotoxicosis, acute thyrotoxic crisis, drug-induced thyrotoxicosis, management of thyrotoxicosis, medical critical care, methimazole adverse reaction, severe thyrotoxicosis, therapeutic plasma exchange (tpe), therapeutic plasmapheresis, thyroid-storm Introduction Thyrotoxicosis is a syndrome caused by an excessive circulation of thyroid hormones, primarily free triiodothyronine (FT3) and/or free thyroxine (FT4) . Patients may also show a decreased serum value of thyroid-stimulating hormone (TSH) due to negative feedback by the elevated T3 and T4 hormones [1,2] . To understand these disturbances in thyroid hormones in relation to thyrotoxicosis, it is important to first consider the causes of thyrotoxicosis. This can include disorders that result in hyperactivity of the thyroid gland such as Graves ' disease or toxic adenomas. Additionally, external sources such as exogenous thyroid hormone administration can lead to an excess of circulating thyroid hormone leading to a thyrotoxic state [1] . Thyrotoxicosis typically manifests with symptoms including palpitations, heat intolerance, weight loss, anxiety, and proximal muscle weakness [1] . A patient may present with tachycardia, lid lag, tremor, and warm moist skin on physical exam [2] . The symptoms of thyrotoxicosis result from a hypermetabolic state induced by elevated thyroid hormones. Thyrotoxicosis should be managed promptly, or it can potentially lead to the patient developing an emergent condition known as severe thyrotoxicosis or thyroid storm [1, 3, 4] . Thyroid storm is a severe form of thyrotoxicosis distinguished by the rapid exacerbation of symptoms and rapid deterioration within days or hours of onset and is associated with a mortality of 10-30%, even with the use of aggressive medical treatment [5, 6]. First-line treatment involves antithyroid drugs or thioamides, most commonly Propylthioura

FAQs

Why was therapeutic plasma exchange used in this case?

TPE was used because the patient developed severe thyrotoxicosis and experienced inadequate management options when conventional protocols were complicated by an adverse reaction to methimazole.

What complication affected conventional treatment of severe thyrotoxicosis?

The patient had an adverse reaction to methimazole, which complicated management by precluding the use of conventional treatment protocols for severe thyrotoxicosis.

What was the outcome after TPE?

Two plasma exchanges stabilized the patient without the need for thyroidectomy or radio-iodine ablation and she was safely discharged home.

Sep 28, 2026

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