You are here: > Teaching Cases and Quiz >> Endocrinology Case 1
Endocrinology Case 1
Submitted by:
Dr. Smita Chinmay Kulkarni, DNB (Nucl Med), FEBNM, FANMB, MNAMS
Assistant Professor,
Department of Nuclear Medicine and Molecular Imaging,
Amrita Institute of Medical Sciences,
Kochi, Kerala, India
A 50 year old female patient with known history of cirrhosis, presented to endocrinology OP with complaints of loss of weight and palpitations of 15 days duration. Clinically she had WHO grade 1 goitre with no discrete palpable nodules. Lab values showed free T4 of 2.84 ng/dl (N- 0.8-2ng/dl), free T3 of 4.9 pg/ml (1.2-4.4 pg/ml) and TSH of <0.05 μIU/ml. Technetium Pertechnetate Thyroid scintigraphy showed homogeneously increased tracer uptake in both lobes of thyroid gland. She was started on Tab. Carbimazole 30 mg per day in 3 divided doses. After 1 month of starting the therapy, she presented with intermittent fever, headaches, sore throat and further weight loss. Complete blood counts showed Hb- 9.6 mg/dl, RBC count – 3.4 M/μL, WBC count of 2500 cells/μL with 10.2% Neutrophils and CRP – 70 mg/L, TSH – 0.02 μIU ml, FT4- 2.04 ng/dl and FT3 – 4.1 pg/ml. What is the diagnosis and according to ATA guidelines which is the best modality of treatment for this patient?
Options:
A. Carbimazole induced Agranulocytosis and best treatment for this patient is to switch over to Propyl thiouracil.
B. Carbimazole induced Agranulocytosis and best suited treatment for this patient is to stop carbimazole and consider for Radioiodine therapy.
C. Thyroid storm and patient should be managed with intravenous Hydrocortisone.
D. Viral fever and should be given supportive care and the medication should be continued.
Scroll down for correct answer and discussion
Correct answer is B.
Wrong answers and why these are wrong answers:
A . Carbimazole induced Agranulocytosis and best treatment for this patient is to switch over to Propyl thiouracil.
Patient is known case of cirrhosis. Propyl thiouracil is known to cause the drug induced hepatitis and liver failure. Hence better avoided in preexisting liver disease.
C. Thyroid storm and patient should be managed with intravenous Hydrocortisone.
High index of suspicion of thyroid storm should be made based on Burch and Wartofsky score which includes hyperpyrexia, tachycardia, arrhythmias, congestive heart failure, agitation, delirium, psychosis, stupor, and coma, as well as nausea, vomiting, diarrhea, hepatic failure, and the presence of an identified precipitant.
D. Viral fever and should be given supportive care and the medication should be continued.
This should not be ignored as simple viral fever. That would be life threatening to the patient.
References:
Ross, D. S. et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid: official journal of the American Thyroid Association 26, 1343–1421 (2016).
Emiliano AB, Governale L, Parks M, Cooper DS 2010 Shifts in propylthiouracil and methimazole prescribing practices: antithyroid drug use in the United States from 1991 to 2008. J Clin Endocrinol Metab 95:2227–2233
Sarimar Agosto, Sonali Thosani. Thyroid Emergencies in Critically Ill Cancer Patients 1003-1015.