Thyroid storm with concurrent autoimmune hepatitis: a case report on diagnostic challenges and the role of therapeutic plasma exchange.

Abstract

Summary: Thyroid storm represents a severe expression of thyrotoxicosis and is commonly associated by multiple organ dysfunction and liver abnormality. Thyrotoxicosis with concurrent autoimmune hepatitis is rare but could confound liver dysfunction, hence complicating diagnosis and subsequent management. We present the case of a 37-year-old woman with thyroid storm complicated by multiple organ failure and resistant hyperthyroidism. Despite initial medical therapy, her condition deteriorated with rising bilirubin and worsening right heart failure. Therapeutic plasma exchange (TPE) was initiated, leading to transient clinical and biochemical improvements. However, subsequent neurological decline and hepatic decompensation revealed an underlying autoimmune hepatitis, confirmed via biopsy at later stage. Intensive multimodal management, including further TPE sessions, ultimately stabilized her condition, allowing a safe and successful thyroidectomy. This report underscores the diagnostic challenge posed by overlapping autoimmune pathologies, the need for vigilant monitoring of thyroid and hepatic parameters, and the pivotal role of TPE as a rescue therapy.

Learning points: Dual autoimmune pathologies, such as autoimmune hepatitis and Graves' disease, can overlap and complicate diagnosis. Persistent or worsening liver dysfunction despite improvement in other thyroid parameter may signal underlying liver pathology. Importance of monitoring for rebound thyrotoxicosis and liver dysfunction in thyroid storm. Therapeutic plasma exchange (TPE) as a critical rescue therapy in thyroid storm and metabolic or hepatic encephalopathy.