Endocrine Abstracts

We report a 44 year old lady with a history of weight loss, anxiety and ‘prominent eyes’. She was clinically and biochemically thyrotoxic (FT4: 158.1 pmol/L [12–22], FT3:56.5 pmol/L [2.8–7.], TSH:<0.08 mU/L [0.30–4.30]). She was commenced on carbimazole and propranolol. Failure to attend regular clinic appointments or comply with drug therapy over the next few years resulted in huge swings of her thyroid status from severe thyrotoxicosis to profound hypothyroidism (TSH: >100 mU/L). After several years lost to follow up she was admitted to hospital with severe neutropaenia (WCC: 2.9×10⁹/L [4–11×10⁹/L], Neutrophil: 0.22×10⁹/L [2–7.5×10⁹/l]) secondary to carbimazole, which was stopped. Treated with antibiotics, anti-fungals and G-CSF her cell count improved gradually. However she remained unwell and in persistent thyrotoxicosis (FT3: 13.3 pmol/L, TSH: <0.08 mU/L).

Due to issues around compliance she was kept hospitalised while on Lugol’s iodine to render her euthyroid before more definitive treatment with subtotal thyroidectomy. Her blood results started improving and she was discharged home with elective thyroidectomy planned after a fortnight. Due to worsening of thyrotoxicosis again, she was re-admitted and her surgery was postponed. Her medical treatment continued but unfortunately she exhibited the phenomenon of ‘iodine escape’ and her thyroid function tests continued to deteriorate posing her at high risk of perioperative thyroid storm. After thorough consideration of all treatment options she was started on low dose Propylthiouracil and dexamethasone in addition to Lugol’s iodine. Her thyroid function tests showed progressive improvement with a stable cell count rise until 5 days prior to surgery when she developed agranulocytosis. Her Propylthiouracil was therefore discontinued. She underwent subtotal thyroidectomy under antibiotic cover and made an uneventful recovery. Our case illustrated that although thyrotoxicosis is a common condition its treatment can remain a challenge. All treatment options of thyrotoxicosis has its own risks and benefits and therefore treatment should be tailored to patient specific considerations.