Endocrine Abstracts

Female patient (56 y) with hyperthyroidism (start TSH 0.01 mIU/l; fT3 15.8 pmol/l; fT4 39.4 pmol/l) one month after initiation of thiamazole therapy (10 mg 3 × 1/1 week, then 2 × 1) came to the emergency room with symptoms of sweating, palpitations, nervousness, itching, fever (37.6 C), icterus. In medical history: oesophageal achalasia surgery 5 years ago, non-smoker. Therapy: thiamazole, bisoprolol, alprazolam. Initially in laboratory findings: leukopenia (L 1.2 × 109/l), liver lesion (total bilirubin 196 µmol/l, AST 71 U/l, ALT 69 U/l, ALP 558 U/l, GGT 379 U/l) and elevated CRP (183.4 mg/l). During hospitalization a progression of pancytopenia (L 0.7 × 109/l), worsening of the liver lesion and CRP (total bilirubin up to 267 umol/l, ALP 294 U/l, GGT 153 U/l, CRP 346 mg/l) were recorded. TSH was 0.01 mIU/l with elevated fT3 10.6 pmol/l and fT4 42.7 pmol/l. Abdominal ultrasound found no signs of bile duct obstruction, there was visible splenomegaly. Gastroscopy found gastritis and oesophageal mycosis, acute tonsillopharyngitis. Cytological analysis of the bone marrow showed poor cellular bone marrow with marked neutropenia. Haemocultures, urinocultures, markers of hepatitis and serology EBV IgM were negative. She was treated with antibiotic therapy piperacillin + tazobactam, later replaced with vancomycin + meropenem + fluconazole. Despite antibiotics, filgrastim and symptomatic therapy hyperbilirubinemia persisted, leukopenia and synthetic liver function were worsening. She was transferred to a tertiary institution for further treatment, without the criteria for inclusion on the liver transplant list. Sixteen days after initial hospitalization, J-131 therapy was performed (296 mBq/8 mCi), then lithium carbonate 150 mg 1 × 1 was added to therapy for several months; euthyroidism was achieved. Sixteen months after the described toxic reaction to thiamazole, mild hyperthyroidism was noticed, followed by spontaneous euthyroidism, with a negative finding of scintigraphy and no need for therapy. In conclusion: thionamides are the most common initial therapy for hyperthyroidism. A toxic reaction is also possible with low doses of thiamazole. Regular follow up of thyroid test is required.

Keywords: thyrotoxicosis, thiamazole, toxic liver lesion.