Endocrine Abstracts

We present here the case of a 33-year-old woman, previously fit and well who presented initially with thyrotoxic symptoms. TFTs showed TSH <0.05, fT3 40. Thyroid uptake scan showed homogenous uptake of 8%. She was prescribed carbimazole 40 mg od and propanolol 40 mg bd with improvement.

One month later, she presented to A+E with abdominal pain associated with diarrhoea and vomiting. She was found to be unwell, tachycardic and febrile. She had a globally tender abdomen with a possible RIF mass and was guarding but had preserved bowel sounds. Blood tests showed: CRP 200, compensated metabolic acidosis, TSH <0.01, fT3 7.7, Hb 9.6, WBC 0.3, Neutrophils 0.1, Plt 163. CT abdomen with contrast demonstrated oedema of caecum and distal terminal ileum.

A presumptive diagnoses of carbimazole induced agranulocytosis and consequent typhilitis (necrotising enterocolitis) was made. She was managed on ITU. Bone marrow aspirate was performed, confirming cellular arrest. Granulocyte-CSF was given with rapid recovery of WBC.

Laparotomy confirmed terminal ileitis and caecitis. Laparostomy was performed but she proceeded to bowel resection when inotropic requirement increased and acidosis worsened. Post operative recovery was rapid.

She developed tachycardia off inotropes and day 9 TFTs showed TSH <0.05, fT3 18.6, fT4 27.5 and she was hence restarted on Propanolol. Thyroid uptake scan showed 18% uptake and we are considering whether to proceed to I131 ablation or sub total thyroidectomy.

Typhilitis is a rare complication of immunosuppression, not previously described in thionamide induced agranulocytosis. It is characterised by inflammation of caecum and terminal ileum, often progressing to necrosis and perforation. It is recognised in AIDS and in haematological and solid tumour malignancy mainly as a consequence of aggressive chemotherapeutic regimens. Published mortality in these groups is 40–50%. Treatment is primarily surgical although some cases have been successfully managed conservatively.