Endocrine Abstracts

We present the case of a 55 year old woman with Graves’ disease currently in remission but previous agranulocytosis with carbimazole therapy.

She has a past medical history of Sjogrens syndrome on no medication. There is a family history of type 1 diabetes and thyroid disease in several members. She is Caucasian, a non smoker and drinks no alcohol. She is a primary school teacher.

In December 2014 she presented to her GP with palpitations, breathlessness, weight loss and tiredness. She had a fT₄ of 22.6 pmol/l and fully suppressed TSH. She was given beta blocker and 20 mg of carbimazole. One month later, on this dose, she had resolution of symptoms and weight gain but developed fever and sore throat. Blood tests revealed Hb 126 g/l, WCC 2.7×10⁹/l, Plt 348×10⁹/l, neutrophils 0.3×10⁹/l, creatinine 84 μmol/l, ALP 208 IU/l, ALT 37 IU/l, bilirubin 9 μmol/l, TSH 0.07 mU/l, fT₄ 8.6 pmol/l. She was treated as a neutropenic sepsis. Carbimazole was discontinued. She was cultured given i.v. fluids, antibiotics and GCSF. She was nursed in a side room and made a good improvement after 5 days. Her cultures were negative and she was discharged.

In clinic review, March 2015 she continues to feel well with no symptoms of relapse. She has no palpable goitre and no eye signs. She is biochemically euthyroid with fT₄ 13.3 pmol/l, fT₃ 4.2 pmol/l, TSH 0.11 mU/l. TSH receptor antibodies are positive at 1.34 u/ml confirming Graves. Subsequent ultrasound shows 2 left sided nodules 22×9 mm and 3 mm. Both show peripheral and moderate increased vascularity. There is no microcalcification or lymphadenopathy. An uptake scan shows normal uptake levels in keeping with a well controlled multinodular goitre.

In our MDT we felt that relapse is likely and treatment with thionamide drugs is contraindicated. We consider whether we should wait for relapse or prophylactically treat with radioiodine or surgery.