Thyroid storm is a rare, life-threatening endocrine emergency characterized by high mortality and multiorgan dysfunction. Cardiac involvement is common and can progress to profound cardiogenic shock, a fatal complication often refractory to conventional therapies. Acute liver injury also frequently occurs, resulting from direct thyrotoxic effects and systemic hypoperfusion.

Here, we report the case of a 41-year-old female with poorly controlled hyperthyroidism who presented with thyroid storm complicated by cardiogenic shock and cholestatic liver injury. She was successfully managed with a combination of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for circulatory support and therapeutic plasma exchange for rapid thyroid hormone removal.

The patient had a history of poorly controlled Graves' disease who presented to our emergency department with acute palpitations. She was diagnosed with thyroid storm and initial management included propylthiouracil (PTU), Lugol's solution, corticosteroids, and cholestyramine. Despite these interventions, her condition rapidly deteriorated into cardiogenic shock, progressing to cardiac arrest that required three minutes of cardiopulmonary resuscitation. Following return of spontaneous circulation, she remained in profound shock necessitating high-dose vasopressor and inotropic support. Consequently, Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) was initiated for hemodynamic stabilization. However, signs of severe thyrotoxicosis persisted, including atrial fibrillation with rapid ventricular response refractory to cardioversion and worsening cholestatic liver injury. Therapeutic plasma exchange (PLEX) was therefore added for rapid thyroid hormone removal. After 2 cycles of PLEX, her serum T3 level decreased and hyperbilirubinemia resolved. This biochemical control facilitated gradual myocardial recovery, allowing for successful weaning from VA-ECMO and all vasoactive agents 6 days later. The patient was ultimately discharged in stable condition, continuing PTU therapy.

Thyroid storm is a rare, life-threatening endocrine emergency characterized by severe thyrotoxicosis. Conventional management focuses on blocking the synthesis, release, and peripheral effects of thyroid hormones. However, for patients in whom these therapies fail or are contraindicated, therapeutic plasma exchange offers a rapid method for removing circulating thyroid hormones. A devastating complication of thyroid storm is severe cardiac dysfunction, which can lead to profound hemodynamic instability. In these critical situations, Veno-Arterial ECMO (VA-ECMO) can provide vital mechanical circulatory support. This intervention serves as a crucial bridge to recovery, maintaining end-organ perfusion while the underlying thyrotoxicosis is brought under control.