Endocrine Abstracts

30 years old female with history of sinusitis, anxiety states, diagnosed with relapsing multiple sclerosis from May 2005, initially had abnormal sensation and weakness of left side of body with MRI finding of demyelinating lesion in the cervical cord, treated with i/v methyl prednisolone with good recovery. Unfortunately had multiple relapses, therefore treated with two doses of Alemtuzumab since June 2012, presented with shakiness and a rash in her neck in July 2012. Clinical examination showed a BMI of 24.5, no exophthalmos and no pretibial myxoedema but tremulous sweaty hands.

Her thyroid function test showed a tsh of less than 0.05, free t4 of 35 and t3 of 14.7. Was started on carbimazole 20 mg daily by her neurologist and was referred to endocrinology clinic. Her Thyroid receptor antibodies were more than 400 and thyroperoxidase antibodies were more than 1300. After 18 months treatment with carbimazole, was observed with thyroid function tests and had a relapse of thyrotoxicosis in November 2013, she was restarted back on carbimazole. Had a second relapse in September 2015 and received radio iodine due to two relapses, subsequently required thyroxine replacement.

Alemtuzumab is an anti-monoclonal CD52 antibody which is used in relapsing and remitting multiple sclerosis (as Lemtrada), B cell chronic lymphocytic leukaemia, kidney, bone marrow and islet cell transplant (as campath).

Despite the proven efficacy in reducing the relapses and disability in multiple sclerosis, Auto immune disease remains at significant risk. The adverse effect could be due to secondary auto immune disease through suppression of suppressor T lymphocytes. It particularly affects the thyroid gland in up to 20 to 30 percent of patients treated with alemtuzumab.

This case highlights the need for physicians using alemtuzumab to be vigilant on presentations of thyrotoxicosis, which could be subtle clinical presentation and to request thyroid function at the earliest and treat.