Endocrine Abstracts

Introduction: Graves’s disease is an autoimmune condition both cell and antibody-mediated, which is associated with thyrotoxicosis and extra thyroid features.

Case report: A 35-year-old female presented with symptomatic hyperthyroidism due to graves thyrotoxicosis. She developed adverse reactions, including severe dermatitis and hepatotoxicity, to two of the thionamide drugs (carbimazole and propylthiouracil). Eventually we decided for definitive treatment in the form of a total thyroidectomy, as it appeared to be the only option in a mother of a young child, which precludes radioiodine therapy. Unfortunately, we were unable to treat her with a beta-blocker due to her history of severe Raynaud’s disease. We arranged for her to undergo rapid thyroid blockade 10 days prior to her surgery with Lugol’s iodine. After she had Lugol’s iodine, she exhibited a paradoxical increase in her thyroid hormone levels, which was unusual and necessitated cancellation of her surgery. It appears she did not go through the Wolff-Chaikoff effect but instead showed Jod-Basedow effect, resulting in a significant rise in free T₄. We have agreed to commence her on cholestyramine 2 g three times a day and prednisolone 40 mg once a day in order to improve her thyrotoxicosis. Eventually she became euthyroid after a few weeks of starting the treatment and then underwent total thyroidectomy.

Comments: Thionamides are widely used as anti-thyroid drugs in the management of hyperthyroidism but unfortunately they are also associated with serious adverse effects which was exhibited by this patient. In our case we have successfully used adjunct treatment including steroids and cholestyramine to achieve euthyroid state and making patient ready to undergo thyroidectomy. Although steroids are not used as a mode of achieving euthyroid status with hyperthyroidism, though it is often used in thyroid crisis.