Refractory thyrotoxicosis induced by iodinated contrast agents treated with therapeutic plasma exchange. A case report

Excess free iodide in the blood (ingested or injected) may cause thyrotoxicosis in patients at risk. Iodinated contrast solutions contain small amounts of free iodide and may be of significance for patients affected by Graves' disease, multinodular goiter or living in areas of iodine deficiency. Herein, we report a 57 elderly woman with a clinical history of multinodular goiter presented with a thyrotoxicosis induced by an iodinate contrast agent used during computed tomography scan. Because of the patient's resistance to conventional antithyroid drugs, she was treated with therapeutic plasma exchange (TPE). TPE is used in the treatment of several immunologic and nonimmunologic disorders. Temporary improvement after TPE in cases with thyrotoxicosis has been reported. In our patient's case, we observed an improvement in the thyroid hormone laboratory values as well as clinical findings. TPE can be an addition treatment when standard therapies for thyrotoxicosis fail providing the clinician with an adjuvant tool for rapid preparation of such a patient for thyroidectomy surgery.     

Preoperative plasmapheresis experience in Graves’ disease patients with anti-thyroid drug-induced hepatotoxicity

Hepatotoxicity is a rare but serious side effect of antithyroid drug (ATI) therapy in Graves’ disease patients. Cessation of ATI drug is needed in most of the patients if liver enzymes highly elevated or in case of agranulocytosis. Permanent therapy, surgery or radioactive iodine ablation are the treatment choices to ensure euthyroidism in active Graves’ disease patients.Therapeutic plasma exchange (TPE) can be an option to ensure euthyroidism, especially in patients scheduled for urgent surgery. In the present study, we present consecutive five cases of methimazole related severe hepatotoxicity that underwent TPE before thyroid surgery. The median number of apheresis sessions was 3 (range: 2–5). Free triiodothyronine (FT3) 65–83 %, free thyroxine (FT4) 22–66 %, thyrotropin receptor antibodies (TRAB) 55–96 % decreases were observed. All patients underwent total thyroidectomy. TPE is an effective method to reduce serum FT3, FT4, TRAB levels in the short term to provide better thyroid hormone status before urgent surgery in ATI induced toxic hepatitis patients.     

Therapeutic plasma exchange for control of thyroid storm

Therapeutic plasma exchange (TPE) for thyroid storm has recently been upgraded to a category II indication after decades though its recommendation level still remains at Grade 2C according to the American Society for Apheresis (ASFA). In the absence of prospective randomized controlled trials due to the rarity of thyroid storm, retrospective data from case series continue to elevate the clinical evidence supporting TPE as a life‐saving modality for complicated thyroid storm patients. We report three cases of life‐threatening thyroid storm from Graves' disease rescued by TPE via rapid reduction in circulating thyroid hormones. Each patient underwent TPE when it was judged that other thyroid storm treatment options were futile or unsafe. The first patient received 4 cycles of TPE while the second patient received 9 cycles of TPE, and the third patient received 2 cycles of TPE with satisfactory clinical improvement. Plasma FT4 and TSH receptor antibody levels of the first case declined by 41.3% and >50% respectively right after the first round of TPE; plasma FT4 of the second patient dropped by up to 31.6% during the course of TPE; plasma FT4 and TSH receptor antibody of the third patient declined by 66% and 56.2% respectively after the first cycle of TPE. This demonstrates the safety, efficacy, and feasibility of TPE in thyroid storm especially when other therapeutic interventions are contraindicated. TPE operates via the elimination of serum proteins‐bound thyroid hormones, thyroid autoantibodies, cytokines, and catecholamines in addition to increasing unsaturated binding sites for thyroid hormones.     

Iatrogenic thyrotoxicosis and the role of therapeutic plasma exchange

Thyroid storm or severe thyrotoxicosis results from extreme thyroid hormone elevation. Therapy includes medical management to prevent hormone production, release, recycling, and peripheral conversion while stabilizing adrenergic tone. Thyroid dysfunction is the usual cause but it can be due to excessive thyroid hormone ingestion. Therapeutic plasma exchange (TPE) has been used to rapidly remove protein‐bound thyroid hormone. American Society for Apheresis guidelines make a weak recommendation to perform TPE in selected patients in the treatment of thyrotoxicosis based on low quality evidence. We present a case of excessive thyroid replacement hormone ingestion treated by TPE. The patient presented with the clinical picture of thyroid storm, including cardiovascular compromise and massively elevated total and free T3 (525 ng/dL, nl 80–200 ng/dL and 28 pg/mL, nl 2.0–3.5 11 pg/mL), which failed medical therapy. A single, one plasma volume TPE was performed. Both total and free T3 demonstrated substantial declines immediately after TPE with the patient's mental status returning to near‐normal. Thyroid hormone extraction efficiency and collection efficacy were calculated as 37.1% and 40.8%, respectively. Prior to discharge on day 6, the patient's compounding pharmacy indicated that a “bad batch” of bovine thyroid gland derived replacement hormone had been produced. TPE appears to be effective in removing protein bound thyroid hormone in extreme iatrogenic thyrotoxicosis.     

Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure:A case report

BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis,characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases,such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure.CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting,diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure.Moreover, she also suffered from heart failure. Therapeutic plasma exchange(commonly known as TPE) and continuous renal replacement therapy(commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests.CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.     

Prise en charge en réanimation du coma myxoedémateux et des formes graves de thyrotoxicose

Hypothyroidism and hyperthyroidism, generally benign conditions, may result in severe features leading to patient admission to the intensive care unit (ICU). Myxedema coma, generally related to the non-compliance with replacement therapy in a patient with chronic hypothyroidism, is characterized by coma associated with hypothermia, bradycardia, and respiratory failure. Thyroid hormone measurement allows the diagnosis. Protocols with rapid intravenous administration of high doses of thyroid hormones, together with warming and mechanical ventilation, have improved the prognosis which remains severe with 50% mortality rate. Nowadays, severe forms of thyrotoxicosis admitted to the ICU are more frequently amiodaroneassociated thyrotoxicosis (whose severity is related to the presence of underlying cardiac diseases) than classic thyroid storms. Treatment of thyroid storm with antithyroid drugs, corticoids, and beta-blockers is generally effective and allows avoiding the need for plasma exchange or emergency thyroidectomy. Prognosis of thyroid storm has improved but remains severe with 20% mortality rate. Diagnosis of the mechanism of amiodarone-induced thyrotoxicosis (type 1 versus type 2) is crucial for treatment. In type 1 (latent preexisting hyperthyroidism worsened by iodine excess), treatment is similar to the one proposed for thyroid storm; in type 2 (thyrotoxicosis related to amiodarone-induced destructive thyroditis), antithyroid drugs are ineffective and treatment relies on corticoids at high doses. However, in these cases, interruption of amiodarone may not be mandatory.     

The results of therapeutic plasma exchange in patients with severe hyperthyroidism: A retrospective multicenter study

Hyperthyroidism characterized by elevated serum levels of circulating thyroid hormones. The aim of hyperthyroidism treatment is to achieve a euthyroid state as soon as possible and to maintain euthyroid status. However, drug withdrawal and utilization of alternative therapies are needed in cases in which leucopenia or impairment in liver functions is observed during medical therapy. In the present study, we aimed to present our cases which underwent therapeutic plasma exchange (TPE) due to severe hyperthyroidism. The results of 22 patients who underwent therapeutic plasma exchange due to hyperthyroidism in Apheresis Units of Erciyes University and Gaziantep University, between 2006 and 2012, were retrospectively reviewed. These cases had severe thyrotoxic values despite anti-thyroid drug use. After TPE, we observed a significant decrease in free thyroxin (FT4) (p < 0.001) and free triiodotyhronin (FT3) (p < 0.004) levels. There was statistically significant increase in the mean values of TSH levels after TPE (p < 0.001).Clinical improvement was achieved in hyperthyroidism by TPE in 20 cases (91%). Both FT3 and FT4 levels remained above the normal limits in two of 22 patients. TPE should be considered as an effective and safe therapeutic option to achieve euthyroid state before surgery or radioactive iodine treatment. TPE is a useful option in cases with severe hyperthyroidism unresponsive to anti-thyroid agents and in those with clinical manifestations of cardiac failure and in patients with severe adverse events during anti-thyroid therapy.     

Perfect storm: Therapeutic plasma exchange for a patient with thyroid storm

Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First‐line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8‐2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8‐1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.     

慢性丙型肝炎患者血清甲状腺激素水平及甲状腺自身抗体的分析

目的探讨慢性丙型肝炎、代偿性丙型肝炎肝硬化、失代偿性丙型肝炎肝硬化时甲状腺激素水平的变化及甲状腺自身抗体存在状况。方法分别检测慢性丙型肝炎42例、肝硬化代偿期37例、肝硬化失代偿期36例、健康体检者30例的血清促甲状腺激素（TSH）、甲状腺素（T4）、三碘甲状腺原氨酸（T3）、游离甲状腺素（FT4）、游离三碘甲状腺原氨酸（FT3）、抗甲状腺过氧化物酶抗体（抗TPO）、抗甲状腺球蛋白抗体（抗TG）的含量。结果与正常对照组相比：T3,T4在各观察组均显著降低;FT3在肝硬化组,FT4在失代偿性肝硬化组显著降低;TSH在慢性丙型肝炎组降低,在肝硬化组升高;抗TPO、抗TG在各观察组均显著增高。结论慢性丙型肝炎患者甲状腺激素相关物质的检测可以帮助评估病情程度。     

Therapeutic plasma exchange and a double plasma molecular absorption system in the treatment of thyroid storm with severe liver injury: A case report

BACKGROUND Thyroid storm is resistant to conventional treatments including antithyroid drugs and 131I therapeutic means.Plasma exchange(PE)and double plasma molecular absorption system(DPMAS)can be used as an effective treatment for thyroid storm with severe liver injury.CASE SUMMARY A 52-year-old woman presented with a 10-day history of nausea and vomiting accompanied by yellowing of the skin and mucosa.Further,her free T3(FT3)and FT4 levels were significantly elevated,whereas her thyrotropin level was reduced.After admission,her condition continued to deteriorate,and she presented with continued high fever,vomiting,palpitation,and shortness of breath.After being diagnosed with thyroid storm,the patient was immediately treated with PE combined with DPMAS.Her symptoms improved immediately.After three PE+DPMAS treatments,and she was discharged from the hospital.She was treated with methylprednisolone and methylthimidazole.After six months,the patient spontaneously discontinued methylthimidazole treatment.Her previous clinical manifestations and liver dysfunction reoccurred.The patient was treated with PE+DPMAS two times,and her condition rapidly improved.Liver histopathology indicated immunological liver injury.CONCLUSION Our experience suggests that PE combined with DPMAS can effectively relieve the development of thyroid storm.     

Transient hyperthyroidism after total parathyroidectomy for tertiary hyperparathyroidism: A report of two cases

Surgical removal of enlarged parathyroid glands is the treatment of choice in most cases of tertiary renal hyperparathyroidism. Complications of this surgical procedure are rare. We report two cases of patients who developed acute hyperthyroidism after total parathyroidectomy with parathyroid autotransplantation for refractory tertiary hyperparathyroidism. The patients had no history or biochemical or radiologic evidence of thyroid disease. They were not taking drugs affecting thyroid function. Thyroid function (thyroid stimulating hormone, free T(3) and free T(4)) was measured preoperatively, immediately after surgery and again three months later. Total parathyroidectomy was successful in both patients. Circulating levels of parathyroid hormone were at the lower limit of normal values. Postoperative thyroid function tests demonstrated acute hyperthyroidism with a rapid increase in free T(3) and T(4) levels above normal and a drop in thyroid stimulating hormone below normal in both patients. The course of hyperthyroidism was short (normalization of fT(3) and fT(4) values within 14-21 days). Neither patient had symptoms of thyrotoxicosis. Transient hyperthyroidism may be an under-recognized complication of total parathyroidectomy for tertiary hyperparathyroidism. These patients should be monitored with thyroid function tests and assessed for clinical signs attributable to thyrotoxicosis.     

Free thyroxin index and direct measurements of free thyroxin compared for evaluating postpartum autoimmune thyroid dysfunction

Measurement of free thyroxin (FT4) by a recently introduced commercial assay (Amerlex Free T4 RIA) was compared with the calculated free thyroxin index (FT4I) for serum from 104 postpartum women. Of these, 63 had transient thyroid dysfunction due to autoimmune thyroiditis, six had transient Graves' thyrotoxicosis, and 35 were euthyroid with no signs of autoimmune thyroid disease. The correlation between results for FT4 and the calculated FTI for 95 serum samples from women with no signs of autoimmune thyroiditis (r = 0.941; p = 0.0001) was almost identical to that for 270 serum samples from women with thyroid microsomal autoantibodies characteristic of autoimmune thyroiditis (r = 0.937; p = 0.0001). Furthermore, we observed no difference when the autoimmune group was subdivided according to low or high titers of thyroid microsomal antibodies. In no case did autoantibodies to thyroxin interfere with the FT4 assay. However, one woman had a spuriously low value for FT4I owing to interference by autoantibodies to triiodothyronine with the triiodothyronine resin uptake test. We conclude that the FT4 RIA assay provided diagnostic information in this group of postpartum women equivalent to that of the more elaborate procedure of determining FT4I.     

Incidence and predictors of thyroid dysfunction caused by long-term intake of amiodaron

AIM: To analyze occurrence of thyroid dysfunction due to regular long-term intake of amiodaron (for one year), to search for predictors of amiodaron-induced hypothyroidism and thyrotoxicosis. MATERIAL AND METHODS: Sixty two patients with different types of arrhythmia have undergone examination including tests for TTH (once in three months), free T3 and T4 (once in 6 months), ultrasound thyroid investigation, general clinical and physical check-up, resting ECG in 12 leads, echocardiography, chest x-ray, biochemical blood tests, blood count, urinalysis. RESULTS: Amiodaron intake for 1 year was associated with amiodaron-induced thyroid dysfunction in 25% patients: 19.2% developed hypothyroidism, 5.8%--thyrotoxicosis. Organic pathology of cardiovascular system, cardiac failure, left ventricular aneurysms, low global myocardial contractility, organic thyroid pathology, elevated levels of antithyroid antibodies predicted hypothyroidism. Thyrotoxicosis was associated with a young age and male sex. CONCLUSION: Amiodaron may cause thyroid dysfunction in patients with arrhythmia.     

Thyroid storm and warm autoimmune hemolytic anemia

Graves’ disease is often associated with other autoimmune disorders, including rare associations with autoimmune hemolytic anemia (AIHA). We describe a unique presentation of thyroid storm and warm AIHA diagnosed concurrently in a young female with hyperthyroidism. The patient presented with nausea, vomiting, diarrhea and altered mental status. Laboratory studies revealed hemoglobin 3.9 g/dL, platelets 171 × 10⁹ L^?1, haptoglobin <5 mg/dL, reticulocytosis, and positive direct antiglobulin test (IgG, C3d, warm). Additional workup revealed serum thyroid stimulating hormone (TSH) <0.01 μIU/mL and serum free-T4 (FT4) level 7.8 ng/dL. Our patient was diagnosed with concurrent thyroid storm and warm AIHA. She was started on glucocorticoids to treat both warm AIHA and thyroid storm, as well as antithyroid medications, propranolol and folic acid. Due to profound anemia and hemodynamic instability, the patient was transfused two units of uncrossmatched packed red blood cells slowly and tolerated this well. She was discharged on methimazole as well as a prolonged prednisone taper, and achieved complete resolution of the thyrotoxicosis and anemia at one month. Hyperthyroidism can affect all three blood cell lineages of the hematopoietic system. Anemia can be seen in 10–20% of patients with thyrotoxicosis. Several autoimmune processes can lead to anemia in Graves’ disease, including pernicious anemia, celiac disease, and warm AIHA. This case illustrates a rarely described presentation of a patient with Graves’ disease presenting with concurrent thyroid storm and warm AIHA.     

Surgery of the thyroid.

The sophistication of current surgical treatment of thyroid disorders reflects a better understanding of the pathophysiology. The development of more methods of therapy with antithyroid drugs, beta-adrenergic blocking agents, thyroid hormones, and radioactive isotopes as well as external irradiation has had an important effect on the role that surgery plays in the management of diseases of the thyroid. Iodine, which was use for many disorders, is now probably contraindicated except for preparation of the hyperthyroid patient for surgical treatment. Surgery has now taken its place as one form of therapy for an endocrine organ that is subject to a variety of diseases. It is necessary for the surgeon who undertakes operations on the thyroid to have an understanding of thyroid physiology as well as its pathophysiology.     

Subacute thyroiditis manifesting as fever of unknown origin

Subacute thyroiditis (SAT) usually occurs in women in middle age with a viral prodrome, thyroid or neck tenderness, classic symptoms of thyrotoxicosis, and elevated erythrocyte sedimentation rate (ESR). We report a case in an 81-year-old man who initially had 2 days of fever to 101.2 degrees F, confusion, and bilateral lower extremity weakness. Extensive evaluation was remarkable only for the following laboratory values: thyrotropin (TSH) 0.02 microIU/mL, free thyroxine (FT4) 3.1 ng/dL, free triiodothyronine (FT3) 6.0 pg/mL, and ESR 98 mm/hr. One week later, the patient had persistent fevers to 102 degrees F; no source was found. The fever resolved, and 3 months later the patient had profound hypothyroidism (TSH >44.0 microIU/mL, FT4 0.4 ng/dL, ESR 13 mm/hr). A painless thyroid gland and atypical manifestations of hyperthyroidism are unusual in SAT. When fever is of unknown origin, SAT should be considered even if classic features are absent.     

Iodine responsive autoimmune thyroid diseases]

Iodine is an important element for the thyroid and regulates iodine accumulation, thyroid hormone synthesis and hormone release. As a result, dietary iodine deficiency is largely responsible for the production of T3 thyrotoxicosis. Supplemental iodine significantly elevated incidence of iodine induced hyperthyroidism in endemic goiter area. Even in normal iodine area, intake of iodine sometimes accelerates recurrence of hyperthyroid Graves' disease in antithyroid drug treated patients. In contrast, a possible role of iodine on Hashimoto's thyroiditis is not known. As a therapeutic means, excess iodide is used for rapid control of thyrotoxicosis and thyrotoxic crisis. Experimental studies indicated that excess iodide blocks thyroid hormone release by inhibiting thyroid stimulators. This blocking action is ascertained by measuring cAMP, colloid droplets formation and microscopic techniques. Excess iodide does induce hypothyroidism in Hashimoto's thyroiditis.     

Rapid reduction of extremely high kappa free light chains in a patient with myeloma cast nephropathy

This report describes a patient with light chain myeloma and acute renal injury. Serum kappa free light chain (FLC) was extremely elevated, >33,000 mg/dL. Treatment with therapeutic plasma exchange (TPE) started day 2 for biopsy‐confirmed cast nephropathy. Bortezomib‐containing chemotherapy was initiated on day 5, and hemodialysis for tumor lysis syndrome on day 7. TPE alone decreased kappa FLC >70% by day 5, indicating direct FLC removal was successful in this patient. A total of 25 TPE procedures were performed in a 31‐day hospitalization. Hemodialysis was discontinued after 3 months, and the patient's renal function and kappa FLC remain stable. Although the use of TPE for FLC removal is controversial, recent evidence supports its use as adjuvant therapy for acute renal injury secondary to myeloma cast nephropathy. TPE can be effective for rapidly reducing FLC; however, several TPE procedures might be required to reduce the risk of hemodialysis dependency.     

Schilddrüsenautonomie: Gibt es eine "Organhyperthyreose" bei "euthyreoten" Patienten?

Zusammenfassung Hintergrund: Gegenwärtig kennen wir zwei verschiedene Formen der Hyperthyreose, und zwar die klassische oder manifeste und die subklinische oder latente Hyperthyreose, und orientieren uns dabei sowohl an einer entsprechenden hyperthyreoten Symptomatik als auch an pathologischen Laborwerten für FT3, FT4 und TSH basal. Ziel: Wir beschreiben eine neue Form der Hyperthyreose, für die wir die Bezeichnung "Organhyperthyreose" vorschlagen und die sich durch eine meist milde hyperthyreote Symptomatik bei nachgewiesener Schilddrüsenautonomie, jedoch nicht durch pathologische Laborwerte für FT3, FT4 und auch TSH basal auszeichnet. Patienten und Methoden: An insgesamt 33 Patienten mit nuklearmedizinisch nachgewiesener Schilddrüsenautonomie wurde ein Vergleich der vorhandenen hyperthyreosetypischen Symptomatik bzw. Untersuchungsbefunde mit den entsprechenden Laborwerten durchgeführt. Hierzu wurde in zwei Gruppen unterteilt: 19 Patienten mit normalen Werten für FT3, FT4 und TSH wurden der Gruppe mit einer "Organhyperthyreose" zugeordnet, als Kontrolle dienten 14 Patienten mit einer latenten Hyperthyreose bei erniedrigtem oder supprimiertem TSH basal. Ergebnisse: Die Symptomatologie in beiden Gruppen war statistisch signifikant nicht voneinander verschieden, wobei insgesamt nur milde Symptome einer Hyperthyreose beobachtet wurden. Entsprechend der Symptomatik wurden die therapeutischen Optionen mit den Patienten erörtert. Eine Falldarstellung beschreibt eine Patientin, bei der eine Alkoholobliteration eines autonomen Adenoms durchgeführt wurde. Schlußfolgerung: Eine Schilddrüsenautonomie führt bei Patienten mit Normalwerten für FT3, FT4 und TSH zu einer vermehrten Bioverfügbarkeit von Schilddrüsenhormonen an verschiedenen Organen. Wir erklären dies durch eine vermehrte T4-Produktionsrate mit vermehrter Konversion zu thyreomimetisch aktiven Jodthyroninen, die in peripheren Organen eine Hyperthyreose hervorrufen, die Hypophyse aber aussparen können. Die Therapie richtet sich, wie bei der latenten Hyperthyreose, vorzugsweise nach der Klinik und den Bedürfnissen des Patienten. Abstract Background: Classic thyrotoxicosis is defined as the clinical syndrome of hypermetabolism that results when concentrations of serum free thyroxine (fT4), serum free triiodthyronine (fT3), or both are increased and serum level of TSH is suppressed. The term of subclinical thyrotoxicosis refers to a usually asymptomatic state associated with normal serum fT4 and fT3 and low serum TSH concentrations. Aim: We describe a new entity of thyrotoxicosis under the term of "organ-selective thyrotoxicosis". This refers to patients with mild clinical symptoms of thyrotoxicosis and with a non-suppressible thyroid toxic adenomas and normal serum concentrations of fT4, fT3 and TSH. Patients and Methods: We compared symptoms and clinical signs of thyrotoxicosis with serum levels of fT4, fT3 and TSH in 33 patients with toxic adenomas. These patients were divided into 2 groups, 19 patients had normal concentrations of serum fT3, fT4 and TSH belonging to the group of "organ-selective thyrotoxicosis", 14 patients with subclinical thyrotoxicosis were in the control group. Results: In both groups, mild symptoms of thyrotoxicosis were apparent but there was no significant difference between the 2 groups detectable. Therapeutic options were discussed with the patients referring to their symptoms. We describe 1 case of a female patient, in which we carried out an alcohol obliteration of a single toxic adenoma. Conclusion: Biological availability of thyroid hormones in patients with toxic adenomas might be elevated in selected organs although serum levels of fT4, fT3 and TSH are normal. This might be due to an increased production rate of T4 on the one hand and a specific peripheral T4/T3 conversion rate on the other hand. This might lead to an organ-selective thyrotoxicosis in the periphery without concerning the thyrotroph, so that TSH stays within the normal range. Necessity of therapeutic interventions depend on clinical signs and symptoms.     

Therapeutic plasma exchange in the treatment of neuroimmunologic disorders: review of 50 cases.

Therapeutic plasma exchange (TPE) has been used for the treatment of neurologic diseases in which autoimmunity plays a major role. We reviewed the medical records of our patients who had consecutively been treated by TPE between January 1998 and June 2000. Neurological indications included myasthenia gravis (30 patients), multiple sclerosis attack (6 patients with remitting-relapsing course and 3 patients with secondary progressive course), Guillain-Barrè syndrome (6 patients), paraproteinemic neuropathy (2 patients), and chronic inflammatory demyelinating neuropathy (CIDP), transverse myelitis due to systemic lupus erythematosus, acute disseminated encephalomyelitis in one patient each. Continuous flow cell separators were used for TPE. TPE was generally given every other day for all of the patients and one plasma volume was exchanged for each cycle. Although the patients with secondary progressive multiple sclerosis (3 patients) and paraproteinemic neuropathy (2 patients) did not show any improvement after TPE, other patients' targeted neurological deficits were improved by TPE. During the TPE procedures, no patient had any morbidity or mortality, and the complications were mild and manageable such as hypotension, hypocalcemia and mild anemia; three patients had septicemia due to the venous catheter used for TPE. TPE is an effective treatment in neurologic diseases in which autoimmunity plays an important role in pathogenesis, and it is safe when performed in experienced centers.