scholarly journals Propylthiouracil-induced agranulocytosis as a rare complication of antithyroid drugs in a patient with Graves’ disease

2019 ◽  
Vol 65 (6) ◽  
pp. 755-760 ◽  
Author(s):  
Patrícia Novais Rabelo ◽  
Paula Novais Rabelo ◽  
Allyne Fernanda de Paula ◽  
Samuel Amanso da Conceição ◽  
Daniela Pultrini Pereira de Oliveira Viggiano ◽  
...  
Keyword(s):  
Total Thyroidectomy ◽  
Beta Blockers ◽  
Rare Complication ◽  
Young Male ◽  
Autoimmune Disorder ◽  
Lithium Carbonate ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Lugol Solution ◽  
Therapeutic Alternatives

SUMMARY INTRODUCTION: Graves’ disease (GD) is an autoimmune disorder characterized by hyperthyroidism. Antithyroid drugs (ATDs) are available as therapy. Agranulocytosis is a rare but potentially fatal complication of this therapy. In this study, we report agranulocytosis induced by propylthiouracil (PTU) in a patient with GD and the difficulties of clinical management. CASE: RNBA, male, 30 years old, with GD, treated with propylthiouracil (PTU). He progressed with pharyngotonsillitis. Then, PTU was suspended and antibiotic, filgrastim, propranolol, and prednisone were initiated. Due to the decompensation of hyperthyroidism, lithium carbonate, dexamethasone, and Lugol's solution were introduced. Total thyroidectomy (TT) was performed with satisfactory postoperative progression. DISCUSSION: We describe here the case of a young male patient with GD. For the treatment of hyperthyroidism, thioamides are effective options. Agranulocytosis induced by ATDs is a rare complication defined as the occurrence of a granulocyte count <500/mm3 after the use of ATDs. PTU was suspended, and filgrastim and antibiotics were prescribed. Radioiodine (RAI) or surgery are therapeutic alternatives. Due to problems with ATD use, a total thyroidectomy was proposed. The preoperative preparation was performed with beta-blocker, glucocorticoid, lithium carbonate, and Lugol solution. Cholestyramine is also an option for controlling hyperthyroidism. TT was performed without postoperative complications. CONCLUSION: Thionamide-induced agranulocytosis is a rare complication. With a contraindication to ATDs, RAI and surgery are definitive therapeutic options in GD. Beta-blockers, glucocorticoids, lithium carbonate, iodine, and cholestyramine may be an adjunctive therapy for hyperthyroidism.

scholarly journals See-Saw Relationship and its Reversal after Immunotherapy in a Case of Graves’ Disease with Coexisting Myasthenia Gravis

2019 ◽  
Vol 10 (01) ◽  
pp. 136-138 ◽  
Author(s):  
Sathish Kumar Mallikarjuna ◽  
S. Sakthi Velayutham ◽  
P. R. Sowmini ◽  
Malcolm K. Jeyaraj ◽  
S. Arunan
Keyword(s):  
Clinical Practice ◽  
Myasthenia Gravis ◽  
Beta Blockers ◽  
Reciprocal Relationship ◽  
The Other ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Immunomodulatory Effects ◽  
The Relationship ◽  
Unique Association

ABSTRACTThe unique association of myasthenia gravis (MG) with Graves' disease in clinical practice emphasizes that one autoimmune disease can coexist with another or many. The relationship between these two entities has remained controversial till date. Some authors have reported a see-saw relationship between these two entities, MG waning with hyperthyroidism and waxing with treatment of hyperthyroidism. Treatment of both these disorders concurrently may be challenging at times as treatment for one entity may worsen the other. The use of beta-blockers and steroids for Graves' disease may worsen myasthenic weakness. Antithyroid drugs can worsen myasthenia probably by immunomodulatory effects. We report a case of Graves' disease coexisting with MG in a reciprocal relationship which was subsequently reversed after immunotherapy.

scholarly journals Graves’ Disease

2021 ◽  
Author(s):  
Sanjay Saran
Keyword(s):  
Older Patients ◽  
Autoimmune Disorder ◽  
Organ System ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Younger Patients ◽  
Skin Symptoms ◽  
Diffuse Goiter ◽  
Pretibial Myxedema ◽  
Symptoms And Signs

Graves’ disease (GD) is an autoimmune disorder characterized by presence of TSH receptor autoantibody. It is most common cause of hyperthyroidism worldwide. Though GD can occur any age but peak incidence is seen during adulthood in between 20 to 50 years of age. GD is more commonly seen in female. GD is primarily disease of thyroid gland but affects multi organ system i.e. heart, liver, muscle, eye and skin. Symptoms and signs are result from hyperthyroidism or a consequence of underlying autoimmunity. Weight loss, fatigue, heat intolerance, tremor, and palpitations are the most common symptoms. Diffuse goiter presents in most of younger patients with thyrotoxicosis but less common in older patients. Graves’ ophthalmopathy and pretibial myxedema are extrathyroidal manifestations of GD which results from action of TSHR autoantibodies on TSHR present onfibroblast, adipocyte and T cells in extrathyroidal tissue. Treatment of GD remains in between antithyroid drugs, radioiodine or surgery. In this review we discuss the diagnosis and management of GD.

scholarly journals Value of Apoptotic, Antiapoptotic, and Cell Proliferation Markers in the Treatment of Graves’ Disease

2018 ◽  
Vol 2018 ◽  
pp. 1-9 ◽  
Author(s):  
Jessica Castro de Vasconcelos ◽  
Icléia Siqueira Barreto ◽  
Patrícia Sabino Matos ◽  
Frederico Fernandes Ribeiro Maia ◽  
Marcos Antônio Tambascia ◽  
...  
Keyword(s):  
Cell Proliferation ◽  
Beta Blockers ◽  
Expression Level ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Thyroid Cells ◽  
Antiapoptotic Effect ◽  
Hyperthyroid State ◽  
Diagnostic Time ◽  
Lower Expression

To better understand the genesis of autoimmunity in Graves’ disease (GD), it is essential to study the mechanism of apoptosis and cell proliferation in thyroid cells and intrathyroidal lymphocytic infiltrate of GD patients. Methods. A cross sectional, observational study performed by evaluating histopathological samples of thyroidectomy products from GD patients using immunohistochemistry. New histological sections were prepared for immunohistochemical analysis with markers of cell proliferation, antiproliferation, apoptosis, and antiapoptosis. Results. Patients with GD who underwent radioiodine therapy (RIT) had a lower lymphocytic expression level of p27Kip1, and those who took beta-blockers had higher expression levels of BID (BH3-interacting domain) and a lower Ki-67 expression level in thyrocytes than those who did not. The association of a shorter diagnostic time with a lower expression level of MCL-1 in thyroid cells suggests that the hyperthyroid state was related to a lower antiapoptotic effect on thyrocytes. In comparison to patients with GD not using antithyroid drugs (ATD), we found a lower expression level of BID in lymphocytes for those who used ATD. Conclusion. In GD, the hyperthyroid state was associated with a lower antiapoptotic effect on thyroid cells. RIT, beta-blockers, and thionamide act by stimulating apoptosis of thyrocytes by intrathyroidal lymphocytes.

scholarly journals MANAGEMENT OF ENDOCRINE DISEASE: Arguments for the prolonged use of antithyroid drugs in children with Graves’ disease

2017 ◽  
Vol 177 (2) ◽  
pp. R59-R67 ◽  
Author(s):  
Juliane Léger ◽  
Jean-Claude Carel
Keyword(s):  
Medical Treatment ◽  
Autoimmune Disorder ◽  
High Volume ◽  
Medical Intervention ◽  
Prolonged Treatment ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Extensive Experience ◽  
Major Disadvantage ◽  
Pituitary Thyroid Axis

Graves’ disease is an autoimmune disorder. It is the leading cause of hyperthyroidism, but is rare in children. Patients are initially managed with antithyroid drugs (ATDs), such as methimazole/carbimazole. A major disadvantage of treatment with ATD is the high risk of relapse, exceeding 70% of children treated for duration of 2 years, and the potential major side effects of the drug reported in exceptional cases. The major advantage of ATD treatment is that normal homeostasis of the hypothalamus–pituitary–thyroid axis may be restored, with periods of drug treatment followed by freedom from medical intervention achieved in approximately 40–50% of cases after prolonged treatment with ATD, for several years, in recent studies. Alternative ablative treatments such as radioactive iodine and, less frequently and mostly in cases of very high volume goiters or in children under the age of 5 years, thyroidectomy, performed by pediatric surgeons with extensive experience should be proposed in cases of non-compliance, intolerance to medical treatment or relapse after prolonged medical treatment. Ablative treatments are effective against hyperthyroidism, but they require the subsequent administration of levothyroxine throughout the patient’s life. This review considers data relating to the prognosis for Graves’ disease remission in children and explores the limitations of study designs and results; and the emerging proposal for management through the prolonged use of ATD drugs.

scholarly journals SUN-525 Successful Surgical Management of Graves’ Disease in Pregnancy

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Dalal Ali ◽  
Gabriela Balan ◽  
Wan Aizad Wan Mahmood ◽  
Enda McDermott ◽  
Rachel Crowley
Keyword(s):  
Total Thyroidectomy ◽  
Beta Blockers ◽  
Left Lobe ◽  
Adverse Outcomes ◽  
Panic Attacks ◽  
Thyroid Storm ◽  
Graves Disease ◽  
Free Triiodothyronine ◽  
Neonatal Icu ◽  
In Pregnancy

Abstract Background: Total thyroidectomy in pregnancy is not a widely used approach for management of Graves’ disease (GD) but is indicated when thyrotoxicosis persists in spite of efforts to optimise thyroid status. Clinical case: A 27-year-old lady with history of GD, presented at the 9th week of her second pregnancy. She had been counselled about anti-thyroid medications but was on carbimazole (CBZ) 30 mg tds and propranolol LA 80 mg od at presentation. She complained of palpitations, heat intolerance, irritability, weight loss and difficulty swallowing. On clinical examination, she had a heart rate of &gt; 100/min and diffusely enlarged goiter with a bruit. Thyroid Ultrasound showed a right lobe of 6.5 x 2.8 x 2.7 cm and left lobe 5.3 x 2.6 x 2.4 cm. Free thyroxine (FT4) was 42.3 pmol/L (12–22), free triiodothyronine (FT3) 9.09 nmol/L (1.3–3.1), and TSH &lt; 0.01 mIU/L (0.27–4.2). TRAB titer was &gt;40 IU/L (0.0–1.75). She was advised to switch to propylthiouracil (PTU) and labetalol to minimize fetal adverse outcomes. She reported that she was unable to afford PTU and requested a switch back to CBZ. During her course of therapy, she had recurrent admissions with thyrotoxicosis, tachycardia, panic attacks and difficulty in swallowing. A decision was made to manage her with total thyroidectomy in the second trimester. She was treated with Lugol’s iodine, beta blockers and CBZ 2 weeks prior to her surgery and there were no immediate post-operative adverse events. Histology was consistent with GD. Her post-op TRAB titer remained &gt;40 IU/L until present. She delivered at 28 weeks of gestation due to threatened premature labor a baby boy who had neonatal thyrotoxicosis, required admission to the neonatal ICU and therapy with flecanide and CBZ. His TSH was 0.09 mIU/L, (FT4) 68.7 pmol/L and TRAB 19.4 IU/L. He is currently 18 months old, well and not on any medications. Conclusion: Poor control of thyrotoxicosis is associated with pregnancy loss, prematurity, stillbirth, thyroid storm, and maternal congestive heart failure. Therefore, pre-pregnancy counseling is crucial to establish Euthyroid state for the safety of mother and fetus. Reference: (1) Davis LE, Lucas MJ, Hankins GD, Roark ML, Cunningham FG. Thyrotoxicosis complicating pregnancy. Am J Obstet Gynecol. 1989;160:63–70. doi: 10.1016/0002-9378(89)90088-4. (2) Vini L, Hyer S, Pratt B, et al. Management of differentiated thyroid cancer diagnosed during pregnancy. Eur J Endocrinol. 1999;140:404–406.

scholarly journals Management of Graves' hyperthyroidism in pregnancy: focus on both maternal and foetal thyroid function, and caution against surgical thyroidectomy in pregnancy

2009 ◽  
Vol 160 (1) ◽  
pp. 1-8 ◽  
Author(s):  
Peter Laurberg ◽  
Claire Bournaud ◽  
Jesper Karmisholt ◽  
Jacques Orgiazzi
Keyword(s):  
Drug Therapy ◽  
Thyroid Function ◽  
Antithyroid Drug ◽  
Autoimmune Disorder ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Limited Effect ◽  
Antithyroid Drug Therapy ◽  
Maternal Thyroid ◽  
In Pregnancy

Graves' disease is a common autoimmune disorder in women in fertile ages. The hyperthyroidism is causedby generation of TSH-receptor activating antibodies. In pregnancy both the antibodies and the antithyroid medication given to the mother pass the placenta and affect the foetal thyroid gland. Thyroid function should be controlled not only in the mother with Graves' hyperthyroidism but also in her foetus.The review includes two cases illustrating some of the problems in managing Graves' disease in pregnancy.Major threats to optimal foetal thyroid function are inadequate or over aggressive antithyroid drug therapy of the mother. It should be taken into account that antithyroid drugs tend to block the foetal thyroid function more effectively than the maternal thyroid function, and that levothyroxin (l-T4) given to the mother will have only a limited effect in the foetus.Surgical thyroidectomy of patients with Graves' hyperthyroidism does not lead to immediate remission of the autoimmune abnormality, and the combination thyroidectomy+withdrawal of antithyroid medication+l-T4 replacement of the mother involves a high risk of foetal hyperthyroidism.ConclusionAntithyroid drug therapy of pregnant women with Graves' hyperthyroidism should be balanced to control both maternal and foetal thyroid function. Surgical thyroidectomy of a pregnant woman with active disease may lead to isolated foetal hyperthyroidism.

scholarly journals Acute Drug-Induced Cholestatic Syndrome in Basedow Graves’ Disease

2020 ◽  
Vol 5 (2) ◽  
pp. 81-85 ◽  
Author(s):  
Robert Aurelian Tiucă ◽  
Alina Mioara Boeriu ◽  
Rareș Adrian Georgescu ◽  
Ionela Maria Pașcanu
Keyword(s):  
Liver Damage ◽  
Therapeutic Option ◽  
Autoimmune Disorder ◽  
Thyroid Stimulating Hormone ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Drug Induced ◽  
Immune Mediated ◽  
Viral Hepatitis A ◽  
Cholestatic Syndrome

AbstractIntroduction: Graves’ disease (GD), an autoimmune disorder caused by high levels of auto-antibodies against the thyroid-stimulating hormone receptor, is considered the most common cause of thyrotoxicosis, characterized by features such as goiter, ophthalmopathy and dermopathy. In our country, the administration of antithyroid drugs (ATD) is the first line of treatment in this disease. Side effects are rare but some of them, such as agranulocytosis or liver damage, may become serious.Case presentation: We report the case of a 20-year-old female patient who was diagnosed with GD after being previously diagnosed with viral hepatitis A. Treatment was initiated with methimazole 30 mg/day, and three weeks later she developed intense hepatic cytolysis and cholestatic syndrome, therefore the ATD was stopped. A suspicion of autoimmune liver disease was raised, and a liver biopsy was performed in order to establish the diagnosis. The next therapeutic option for hyperthyroidism was radioactive iodine (RAI). Three months following RAI, the patient presented severe hypothyroidism, thereupon treatment with levothyroxine was initiated.Conclusions: Although severe acute liver injury is rare, mild liver dysfunction is quite common in patients with GD. The overproduction of thyroid hormones, or the treatment with ATD through immune mediated processes or drug reactions, represent possible mechanisms responsible for liver damage.

scholarly journals Value of total thyroidectomy for Graves' disease in eliminating the risk of recurrence and malignancy: retrospective database analysis of 574 Saudi Arabian patients in 10 years with 2 years follow up

2016 ◽  
Vol 2 (1) ◽  
pp. 6 ◽  
Author(s):  
Bader Hamza Shirah ◽  
Hamza Assad Shirah
Keyword(s):  
Total Thyroidectomy ◽  
Saudi Arabian ◽  
Subtotal Thyroidectomy ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Database Analysis ◽  
Risk Of Recurrence ◽  
Retrospective Database Analysis ◽  
Retrospective Database

<p class="abstract"><strong>Background:</strong> Graves' disease is an autoimmune disease that affects the thyroid gland and frequently results in hyperthyroidism and an enlarged thyroid. Treatment of Graves' disease includes antithyroid drugs, radioiodine (radioactive iodine I-131), and thyroidectomy, either total, or subtotal excision. In this paper, we aim to analyse the outcome of thyroidectomy performed on patients affected by Graves' disease in Medina – Saudi Arabia, and evaluate if thyroidectomy should be considered the first treatment option for all patients with Graves' disease.</p><p class="abstract"><strong>Methods:</strong> A retrospective database analysis of the surgical treatment outcome of 574 Saudi Arabian patients who were affected with Graves' disease between January 2003 and December 2012 was done. The computerized database medical records were reviewed and analysed for preoperative, intraoperative, and postoperative factors.  </p><p class="abstract"><strong>Results:</strong> 194 (33.8%) patients were males, and 380 (66.2%) were females. The average age of patients was 44 ± 2 years. 154 (26.8%) had subtotal thyroidectomy, and 420 (73.2%) had total thyroidectomy performed. There was (0%) recurrent laryngeal nerve injury, and (0%) intraoperative complication were recorded. With a follow up time of 2 years, 7 (1.22%) patients developed recurrent disease (all in subtotal thyroidectomy group). There were no recurrences in the total thyroidectomy patients, and 11 (1.9%) patients were found in histopathology to have papillary thyroid cancer (all in total thyroidectomy group).</p><p><strong>Conclusions:</strong> We conclude that total thyroidectomy is a safe and effective treatment modality for Graves' disease that offers rapid and long-lasting results, in addition to eliminating the risk of recurrence and malignancy. It should be offered to all confirmed Graves' disease patients during counselling.</p>

scholarly journals SUN-520 Graves Disease and T3 Thyrotoxicosis: A Case Report

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Nishanth thalambedu ◽  
Iqra iqbal ◽  
Shristi khanal ◽  
Muhammad Atique Alam Khan
Keyword(s):  
African American Woman ◽  
Beta Blockers ◽  
American Woman ◽  
Care Physician ◽  
Definitive Treatment ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Free T4 ◽  
Duration Of Action ◽  
Definitive Therapy

Abstract Introduction: Hyperthyroidism is one of the common problems in the world of endocrinology. Identifying the type of thyrotoxicosis is crucial before starting treatment. We present a case of a 37-year-old woman presented with hyperthyroidism and was started on methimazole. Her symptoms persisted and further workup showed T3 thyrotoxicosis. Her symptoms improved after switching her to PTU. She eventually underwent thyroidectomy. Case description: Thirty-seven-year old African American woman presented to her primary care physician(PCP) with symptoms suggestive of hyperthyroidism for three months. Her past medical history is significant for recent delivery one year ago. Her Physical exam is pertinent for hypertension of 160/80 with a heart rate of 120. Her neck is diffusely enlarged with bilateral bruits. Bilateral lid retraction with lid lag was noted along with left lid proptosis. There were no tremors or leg swelling noted. Her Initial workup showed sinus tachycardia in the electrocardiogram. Her TSH level was &lt;0.010 and a free T4 level of 3.48. Ultrasound showed diffuse enlargement of the thyroid gland with no focal nodule. She was started on methimazole 10mg twice daily and metoprolol 25mg twice daily. Three months later, she presented to the emergency room(ER) with tachycardia of 130 and hypertension of 170/85. Work up showed a TSH level of &lt;0.010 and a free T4 level of 3.94. She was compliant with medications. When free T3 levels were checked it turned out to be &gt;30. She was diagnosed with T3 Thyrotoxicosis and was started on propylthiouracil 150mg every 8 hours. Her metoprolol was increased to 50mg every 12 hours. Her symptoms improved and she finally underwent surgery for thyroidectomy. Discussion: Hyperthyroidism is seen in about 1 in 5000 with a strong female predominance. Graves disease, the most common cause of hyperthyroidism is due to excess production of TSH receptor stimulating antibodies. Hyperthyroid patients with graves disease sometimes have a disproportionate increase in serum T3 levels when compared to serum T4. This is thought to be due to increased T3 production or extrathyroidal conversion of T4 to T3. It is very crucial to identify the free hormone levels in a new patient with hyperthyroidism because of the difference in management. Antithyroid drugs are traditionally the first-line treatment option along with beta-blockers prior to definitive therapy like radioactive iodine or thyroidectomy. The main drugs used are methimazole and propylthiouracil(PTU). Methimazole is more commonly used than PTU because of its rapid efficacy, longer duration of action and less adverse effects. For patients with T3 thyrotoxicosis, PTU is preferred as it is known to reduce the peripheral conversion of T4 to T3. Our patient medication was changed from methimazole to PTU, after which she started to notice improvement. She eventually underwent definitive treatment with thyroidectomy.

Sign in / Sign up

Export Citation Format

Share Document