scholarly journals A Rare Case of Anaphylaxis to Methimazole in a Patient With Graves’ Disease

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A915-A916
Author(s):  
Dave Garg ◽  
Gonzalo Acosta Garcia ◽  
Stephanie Smooke Praw
Keyword(s):  
Total Thyroidectomy ◽  
Time Course ◽  
Stable Condition ◽  
Cross Reactivity ◽  
Definitive Treatment ◽  
Graves Disease ◽  
Close Monitoring ◽  
Free T4 ◽  
Delayed Anaphylaxis

Abstract We present the case of a patient with Graves’ Disease (GD) who developed anaphylaxis to methimazole (MMI) necessitating hospitalization, emergent treatment and ultimately urgent total thyroidectomy. While the most common adverse reactions to thionamides include hepatotoxicity, agranulocytosis, pruritis, and urticaria, delayed anaphylaxis has been reported. A 25-year-old woman was diagnosed with GD two years prior to presentation during an admission for syncope. She was started on MMI 10 mg twice a day and propranolol 10 mg three times a day, which she took for roughly one year until she ran out of medication and was lost to follow-up. She remained off MMI until she re-presented several months later grossly thyrotoxic, complaining of fatigue, heat intolerance, unintentional weight loss, blurry vision, and palpitations. Labs were significant for TSH <0.02 mIU/L (normal 0.3-4.7), free T4 >7 ng/dL (normal 0.8-1.7), free T3 >2900 pg/dL (normal 222-383), and thyroid stimulating immunoglobulin (TSI) >500 (normal ≤122). She was restarted on propranolol and MMI 10 mg twice a day which was quickly increased to 20 mg twice a day. Two weeks after restarting MMI, the patient presented to the ER with a diffuse pruritic rash and was treated with antihistamines and steroids. She clinically improved and was discharged in stable condition. Two days later, her symptoms recurred along with flushing, facial/lip swelling, and dysphagia. She presented to our hospital with evidence of angioedema and difficulty breathing. Based on her presentation, anaphylaxis was diagnosed, and she was given intramuscular epinephrine. She was also started on glucocorticoids, H1/H2 blockers and montelukast and was admitted to the ICU for close monitoring. Over the next few days, her symptoms improved. As there was no other recent novel exposure, her anaphylactic reaction was attributed to MMI. Given the life-threatening nature of the reaction, there was concern for trialing propylthiouracil (PTU) due to its known cross-reactivity with MMI. Thus, treatment with propranolol, steroids and potassium iodide was initiated with improvement in her thyroid labs. As the patient would be unable to tolerate anti-thyroid agents in the future, it was decided to pursue definitive treatment with total thyroidectomy given the presence of eye disease. Anaphylaxis secondary to MMI is very rare, and less than a handful of cases have been reported. However, they seem to share two key features: their occurrence with higher doses of MMI (≥40 mg daily), and a delayed onset of presentation (2-4 weeks from exposure). The mechanism is unknown, although it is unlikely to be IgE-mediated given its time course. Current ATA guidelines recommend against using MMI or PTU in patients who have developed serious side effects to the other agent. Our case highlights the importance of close monitoring and timely follow-up after initiating anti-thyroid drugs.

scholarly journals Rescue pre-operative treatment with Lugol’s solution in uncontrolled Graves’ disease

2017 ◽  
Vol 6 (4) ◽  
pp. 200-205 ◽  
Author(s):  
Jan Calissendorff ◽  
Henrik Falhammar
Keyword(s):  
Heart Rate ◽  
Thyroid Hormone ◽  
Side Effects ◽  
Definitive Treatment ◽  
Graves Disease ◽  
Free T4 ◽  
Hormone Levels ◽  
Free T3 ◽  
Adherence To Medication ◽  
Thyroid Hormone Levels

Background Graves’ disease is a common cause of hyperthyroidism. Three therapies have been used for decades: pharmacologic therapy, surgery and radioiodine. In case of adverse events, especially agranulocytosis or hepatotoxicity, pre-treatment with Lugol’s solution containing iodine/potassium iodide to induce euthyroidism before surgery could be advocated, but this has rarely been reported. Methods All patients hospitalised due to uncontrolled hyperthyroidism at the Karolinska University Hospital 2005–2015 and treated with Lugol’s solution were included. All electronic files were carefully reviewed manually, with focus on the cause of treatment and admission, demographic data, and effects of iodine on thyroid hormone levels and pulse frequency. Results Twenty-seven patients were included. Lugol’s solution had been chosen due to agranulocytosis in 9 (33%), hepatotoxicity in 2 (7%), other side effects in 11 (41%) and poor adherence to medication in 5 (19%). Levels of free T4, free T3 and heart rate decreased significantly after 5–9 days of iodine therapy (free T4 53–20 pmol/L, P = 0.0002; free T3 20–6.5 pmol/L, P = 0.04; heart rate 87–76 beats/min P = 0.0007), whereas TSH remained unchanged. Side effects were noted in 4 (15%) (rash n = 2, rash and vomiting n = 1, swelling of fingers n = 1). Thyroidectomy was performed in 26 patients (96%) and one was treated with radioiodine; all treatments were without serious complications. Conclusion Treatment of uncontrolled hyperthyroidism with Lugol’s solution before definitive treatment is safe and it decreases thyroid hormone levels and heart rate. Side effects were limited. Lugol’s solution could be recommended pre-operatively in Graves’ disease with failed medical treatment, especially if side effects to anti-thyroid drugs have occurred.

Total thyroidectomy for safe and definitive management of Graves' disease

2013 ◽  
Vol 127 (7) ◽  
pp. 681-684 ◽  
Author(s):  
A Prasai ◽  
P A Nix ◽  
M Aye ◽  
S Atkin ◽  
R J England
Keyword(s):  
Recurrent Laryngeal Nerve ◽  
Total Thyroidectomy ◽  
Nerve Palsy ◽  
Recurrent Laryngeal Nerve Palsy ◽  
Laryngeal Nerve ◽  
Definitive Treatment ◽  
Royal Infirmary ◽  
Graves Disease ◽  
Laryngeal Nerve Palsy

AbstractBackground:The role of total thyroidectomy in the management of patients with Graves' disease remains controversial. However, there is increasing evidence to support the role of the procedure as a safe and definitive treatment for Graves' disease.Method:Patients were identified from a prospective thyroid database of the multidisciplinary thyroid clinic at Hull Royal Infirmary. All case notes were independently reviewed to confirm the data held on the database.Results:Over a 7-year period, the senior author has performed 206 total thyroidectomies for Graves' disease. The incidence of temporary recurrent laryngeal nerve palsy and hypoparathyroidism was 3.4 per cent and 24 per cent respectively. There was one case of permanent unilateral recurrent laryngeal nerve palsy, and 3.9 per cent of patients developed permanent hypoparathyroidism. There has been no relapse of thyrotoxicosis.Conclusion:In the context of a multidisciplinary thyroid clinic, total thyroidectomy should be offered as a safe and effective first-line treatment option for Graves' disease.

scholarly journals Graves’ Disease After Hematopoietic Allogeneic Bone Marrow Transplant in a Patient With Sickle Cell Disease

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A930-A931
Author(s):  
Majid Alameri
Keyword(s):  
Bone Marrow ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Marrow Transplant ◽  
Graves Disease ◽  
Allogeneic Bone ◽  
Cell Disease ◽  
Free T4 ◽  
Post Transplant

Abstract Endocrinopathies are among the most recognized late complications post hematopoietic stem cell transplant (HSCT). Dysfunctions of hormonal axes including the hypothalamus, pituitary, gonads, thyroid and adrenals reported. Moreover, thyroid dysfunctions including thyroiditis, hypothyroidism and hyperthyroidism has been reported to develop 8-32 months after HSCT. We report a 27-year-old male with sickle cell disease diagnosed at age of 5. He had multiple painful vasoocclusive sickle crises treated with blood transfusions, folic acid and rituximab. At age of 21, he presented with sudden right sided weakness and slurred speech. Further investigations, including magnetic resonance imaging of brain revealed occlusion of the left middle cerebral artery resulting in ischemic infarction. Subsequently, he had multiple red blood cell exchange transfusions on regular basis. He remained with residual weakness and slurred speech after rehabilitation. Bone marrow transplant was recommended as a curative treatment for his sickle cell disease by haematology team. A year later, he underwent a geno-identical allogeneic bone marrow transplantation harvested from his brother. He remained well for 22 months post-transplant without any evidence of graft versus host disease. 23 months post-transplant, he presented with loose motions, 2 kg wight loss and fine tremors. He was referred to endocrine department for further workup. Physical examination revealed a small smooth goitre. He had discrete exophthalmos of his left eye without any signs of active inflammation. Thyroid function tests confirmed diagnosis of Graves’ disease with TSH<0.01 milli IU/L, Free T4=23.9 pmol/L, and TSH receptor antibodies of 3.79 IU/ml. Ophthalmological consultation suggested 6 months of selenium supplementation (200 mcg/day) with regular follow up. There has been no family history of autoimmune diseases or thyroid disorders. He started carbimazole (CMZ) 30 mg daily. His symptoms improved within 8 weeks, with normalization of Free T4 and Free T3 (TSH remained suppressed). 18 months later, he remained asymptomatic on carbimazole. He had recurrence of hyperthyroidism symptoms after 4 weeks trail of stopping carbimazole with elevation of Free T4 and Free T3. Carbimazole was restarted and he has been offered other treatment modalities of Graves’ disease. He elected to undergo total thyroidectomy. His sickle cell and blood counts remained stable during follow up period. Conclusion: Transplanted patients carries a life-long risk for developing endocrinopathies post initial transplant therapy. Acknowledging the wide spectrum of post-transplant endocrinopathies, an individualized case based periodic screening can be helpful to improve health outcomes of such patients. Because of the usual late presentation of such endocrine complications, transplanted patients might need life-long endocrine follow-up.

scholarly journals SAT-461 NIFTP: A Painstaking Diagnosis Through the Pathologist’s Eyes

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Sanjita B Chittimoju ◽  
Frederick T Drake ◽  
Stephanie L Lee
Keyword(s):  
Total Thyroidectomy ◽  
Mutational Analysis ◽  
Braf V600e ◽  
Thyroid Neoplasm ◽  
Definitive Treatment ◽  
Graves Disease ◽  
Metastatic Node ◽  
Chronic Thyroiditis ◽  
Non Invasive ◽  
Nuclear Features

Abstract Non-invasive encapsulated follicular variant of papillary thyroid cancer (EFVPTC) was recently reclassified as non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFT-P).1 In 2018, revised and stricter criteria were proposed for a lesion to qualify as NIFT-P including no well-formed papilla or BRAF-V600E mutation.2 We are presenting an interesting case to highlight the importance of scrutinizing pathology slides to diagnose NIFTP with these more strict criteria. 35-year-old female from Puerto-Rico was diagnosed with Graves’ disease. After 2 years of methimazole treatment, total thyroidectomy was planned for definitive treatment of Graves’ disease. During the work up, she was noted to have a cystic nodule in isthmus, a 1.1 cm hypoechoic nodule in left mid-lobe and a 1.1 cm isoechoic rounded mass in left level III neck, which was initially thought to be a lateral aberrant thyroid remnant. Her thyroid uptake scan was consistent with a multinodular goiter with no uptake in the extrathyroidal mass. The mass was biopsied and showed Atypia of Undetermined Significance (AUS) Bethesda III with washout positive for thyroglobulin (Tg). Total thyroidectomy with bilateral central and left lateral neck dissection was performed. The pathology showed an intrathyroidal 1.2 cm EFVPTC with predominant follicular features and <1% papillae, without tumor capsular invasion. The initial diagnosis was NIFT-P with a background of chronic thyroiditis. However, on pathology, the level III neck mass was a 2 cm metastatic node with classical PTC. ThyroSeq mutational analysis of tissue blocks for both the thyroid nodule and lymph node were positive for NCOA4-RET (RET-PTC3) gene fusion, a BRAF-V600E-like mutation found in classical PTC. On review of her pathology, the thyroid lesion was noted to have more than one papilla, though <1% papillae and was >30% solid, hence not qualifying as NIFT-P and her histological diagnosis was changed to EFVPTC. She was staged as AJCC 8th edition stage 1 with intermediate ATA risk for which she received adjuvant therapy of 101 mCi 131I. Although classification into NIFT-P has been shown to reduce overtreatment of low risk encapsulated PTC, pathology slides should be closely scrutinized to ensure fulfillment of all criteria in order for a lesion to qualify as NIFT-P. This will minimize failure to recognize PTCs, that would warrant closer follow up and surveillance for recurrence. 1. Rossi, Esther D, et al. Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features: Update and Diagnostic Considerations—a Review. Endocrine Pathology 30.2 (2019) 2. Nikiforov, Yuri E et al. Change in Diagnostic Criteria for Noninvasive Follicular Thyroid Neoplasm With Papillary-like Nuclear Features. JAMA oncology vol. 4,8 (2018)

scholarly journals Hyperthyroidism and vascular cell adhesion molecule-1 are associated with a low ankle-brachial index

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Yu-Hsuan Li ◽  
I-Te Lee
Keyword(s):  
Cell Adhesion Molecule ◽  
Regression Coefficient ◽  
Ankle Brachial Index ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Vascular Cell Adhesion ◽  
Free T4 ◽  
Vascular Cell ◽  
Cell Adhesion Molecule 1

Abstract We aimed to assess the ankle-brachial index (ABI) in patients with Graves’ disease. In the cross-sectional assessments, 81 patients with drug-naïve Graves’ disease and 235 with euthyroidism were enrolled. ABI and vascular cell adhesion molecule-1 (VCAM-1) levels were assessed. In the prospective follow-up, 32 patients with Graves’ disease were assessed again after antithyroid drugs for at least 4 weeks, and 32 age- and sex-matched controls with euthyroidism were also followed up. Patients with Graves’ disease had a higher VCAM-1 level (1309 ± 292 vs. 1009 ± 168 ng/mL, P < 0.001) and a lower ABI (0.98 ± 0.11 vs. 1.06 ± 0.10, P < 0.001) than those with euthyroidism. ABI was significantly lower in patients with hyperthyroidism and a high VCAM-1 level than in those with euthyroidism and a low VCAM-1 level (regression coefficient: − 0.050, 95% confidence interval [CI] between − 0.080 and − 0.019; P = 0.001). After treatment with antithyroid drugs, the change in free thyroxine (T4) level was inversely associated with the percentage change in ABI (regression coefficient: − 0.003, 95% CI between − 0.005 and − 0.001, P = 0.001). A synergistic effect of VCAM-1 and free T4 on ABI reduction was observed. After a longitudinal follow-up, an increase in ABI was significantly correlated with a decrease in the free T4 level.

scholarly journals Long-term Results after Total Thyroidectomy in Patients with Graves' Disease in Uzbekistan: Retrospective Study

2011 ◽  
Vol 3 (2) ◽  
pp. 79-82
Author(s):  
Said I Ismailov ◽  
Nusrat A Alimjanov ◽  
Bakhodir Kh Babakhanov ◽  
Murod M Rashitov ◽  
Alisher M Akbutaev
Keyword(s):  
Postoperative Complications ◽  
Total Thyroidectomy ◽  
Thyroid Tissue ◽  
Long Term Results ◽  
Graves Disease ◽  
Nerve Paralysis ◽  
Treatment Groups ◽  
Institutional Experience

ABSTRACT Subtotal thyroidectomy has been advocated as the standard treatment for Graves' disease (GD) because of the assumed lower risk of complications compared with total thyroidectomy, and also it provides the chance to avoid thyroxin therapy. The present study aims to examine our institutional experience with total thyroidectomy for GD. Patients were divided into two surgical treatment groups: Total thyroidectomy (TT) (n = 97) and total thyroidectomy with intraoperative thyroid autotransplantation (TTITA) (n = 74). TTITA performed in 74 patients. 0.5 to 2 gm of thyroid tissue was cut into small pieces and autotransplanted into the forearm muscle of the patient. Postoperative complications included eight cases of RLN palsy, two patients had nerve paralysis, two patients underwent tracheostomy, transient hypoparathyroidism in 25 patients, permanent hypoparathyroidism in two cases, wound hemorrhage in two patients. TPOAb levels were increased in 9% of patients with TT whereas in patients with TTITA TPOAb concentrations were elevated in 65% of patients at 3 months follow-up. TRAb in patients with TT were not detected while 20% patients undergone TTITA had high TRAb levels and 13.3% had terminal concentrations at 3 months follow-up. Serum TPOAb and TRAb were detected in none of the patients who underwent TT and TTITA at 1, 3 and 5 years follow-up. Removal of all thyroid tissue offers the best chance of preventing recurrent hyperthyroidism and we saw no increase in postoperative complications in the TT group. We feel that TT is safe and superior for achieving the goal of treatment of Graves' disease.

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up

2012 ◽  
Vol 99 (4) ◽  
pp. 515-522 ◽  
Author(s):  
M. Barczyński ◽  
A. Konturek ◽  
A. Hubalewska-Dydejczyk ◽  
F. Gołkowski ◽  
W. Nowak
Keyword(s):  
Clinical Trial ◽  
Total Thyroidectomy ◽  
Randomized Clinical Trial ◽  
Subtotal Thyroidectomy ◽  
Graves Disease

scholarly journals SAT-336 An Unusual Case of Symptomatic Hypercalcemia from Graves’ Disease in a Young Filipino Female

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Diana Colleen Mandocdoc Dimayuga ◽  
Michael Lim Villa
Keyword(s):  
Primary Hyperparathyroidism ◽  
Thyroid Function ◽  
Complete Blood Count ◽  
Thyroid Function Test ◽  
Thyroid Stimulating Hormone ◽  
Definitive Treatment ◽  
Graves Disease ◽  
Medication History ◽  
Free T4 ◽  
Healthy Family

Abstract Hypercalcemia in hyperthyroidism is usually asymptomatic, and related to a concurrent primary hyperparathyroidism. In this report, we describe a case of symptomatic hypercalcemia secondary to Graves’ disease alone. Case Report. A 24-year-old Filipino female presented to the emergency department with generalized weakness, vomiting and abdominal pain. No other symptoms were noted. She was otherwise previously healthy. Family history was unremarkable. During physical exam, she was noted to have a non tender palpable thyroid gland without bruit. Her ECG showed sinus tachycardia. The complete blood count and electrolytes were normal however, ionized calcium was high at 1.6mmol/L (NV 1–1.3). Renal function was normal. Hydration with saline and Furosemide 20mg once daily was started though calcium levels remained elevated. Other causes of hypercalcemia were excluded as PTH was appropriate suppressed (8.8ng/L; NV 14–72), vitamin D was also suppressed (15.29nmol/L; NV &gt;30). CT scan of chest and abdomen and bone scan did not point to any underlying malignancy nor metabolic bone disease. Medication history was also unremarkable. She was hyperthyroid with a suppressed thyroid stimulating hormone level of 0.004pmol/L (NV 0.55–4.78), free T3 of &gt;20pmol/L (NV 2.3–4.2), free T4 of 8.4pmol/L (NV 0.89–1.76). Thyroid receptor antibody levels were raised at 41.07kU/L (NV &lt;1) supporting the diagnosis of Graves’disease. She was started on propylthiouracil 50mg four times daily, along with propranolol 40mg three times daily. She was subsequently seen after two weeks with normal repeat calcium level and thyroid function test. Conclusion. This report aims to highlight that thyroid disease should always be considered as a cause of hypercalcemia. A concomitant primary hyperparathyroidism should also be evaluated. The definitive treatment for the hypercalcemia is correction of thyroid function.

scholarly journals Graves’ Disease and Treatment Effects on Warfarin Anticoagulation

2014 ◽  
Vol 2014 ◽  
pp. 1-6 ◽  
Author(s):  
Amanda Howard-Thompson ◽  
Alexis Luckey ◽  
Christa George ◽  
Beth A. Choby ◽  
Timothy H. Self
Keyword(s):  
Atrial Fibrillation ◽  
Warfarin Dose ◽  
Graves Disease ◽  
African American Female ◽  
Close Monitoring ◽  
Lower Extremity Edema ◽  
Case Presentation ◽  
Onset Atrial Fibrillation ◽  
New Onset

Background. Hyperthyroidism causes an increased hypoprothrombinemic response to warfarin anticoagulation. Previous studies have demonstrated that patients with hyperthyroidism require lower dosages of warfarin to achieve a therapeutic effect. As hyperthyroidism is treated and euthyroidism is approached, patients may require increasing warfarin dosages to maintain appropriate anticoagulation. We describe a patient’s varying response to warfarin during treatment of Graves’ disease.Case Presentation. A 48-year-old African American female presented to the emergency room with tachycardia, new onset bilateral lower extremity edema, gradual weight loss, palpable goiter, and generalized sweating over the prior 4 months. She was admitted with Graves’ disease and new onset atrial fibrillation. Primary stroke prophylaxis was started using warfarin; the patient developed a markedly supratherapeutic INR likely due to hyperthyroidism. After starting methimazole, her free thyroxine approached euthyroid levels and the INR became subtherapeutic. She remained subtherapeutic over several months despite steadily increasing dosages of warfarin. Immediately following thyroid radioablation and discontinuation of methimazole, the patient’s warfarin dose and INR stabilized.Conclusion. Clinicians should expect an increased response to warfarin in patients with hyperthyroidism and close monitoring of the INR is imperative to prevent adverse effects. As patients approach euthyroidism, insufficient anticoagulation is likely without vigilant follow-up, INR monitoring, and increasing warfarin dosages.

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