Endocrine Abstracts

We report the case of a 34 year old woman with recurrent hyperthyroid Grave's disease. She was initially found to be thyrotoxic in July 1996. Treatment was commenced with carbimazole, of which she received 12 months in a titration regimen. She relapsed in October 1999, six months following the delivery of her first child, and was restarted on carbimazole, remaining euthyroid on a dose of 10mg. She conceived again in May 2002 (whilst on carbimazole) and treatment was continued until August 2002 when she became clinically and biochemically euthyroid. Her second child was born with aplasia cutis on the scalp just posterior to the anterior fontanelle. There were no other birth defects. She conceived again in December 2003 while maintaining euthyroid status (off carbimazole treatment). She relapsed again in February 2004 (16 weeks into her third pregnancy) and in view of her previous history, was commenced on Propylthiouracil. She presented with tonsillitis in March 2004 and was found to have agranulocytosis, with a neutrophil count of 0.3 X 109/l. Propylthiouracil was stopped and the neutrophil count returned to the reference range within 5 days. Treatment was commenced with Propranolol for symptom control and a subtotal thyroidectomy was performed during the second trimester. Biochemical euthyroid status was attained four days post-operatively. She is currently on thyroxine replacement for hypothyroidism. This is a rare presenation where aplasia cutis secondary to carbimazole therapy and agranulocytosis following propylthiouracil treatment has occurred in the same scenario. Agranulocytosis is a recognised side effect of antithyroid treatment with an incidence of less than 0.5%. Aplasia cutis is also an extremely rare but well recognised side effect of carbimazole therapy. The occurrence of both these conditions in a pregnant patient with two young children is unusual and limits treatment options.