Endocrine Abstracts

A 39-year-old female was referred to the emergency department with a sore throat, fever, myalgia and odynophagia. She had presented to her GP three months previously with palpitations, erratic mood and fatigue and had been diagnosed with hyperthyroidism. She had been started on carbimazole 20 mg od and was awaiting review in endocrinology OPD. She had no other past medical history and was a non-smoker. On examination she was tachycardic with a heart rate of 113. She had cervical lymphadenopathy and oropharyngeal exam revealed tonsillitis with exudate. Laboratory work up showed neutropenia with a total white cell count of 0.8 (ref 4-11 x 10⁹/l) and neutrophils of <0.1 (ref 2-7.5 x 10⁹/l). Her thyroid function tests had improved with a TSH of <0.05mU/L (ref 0.3-4.2mUl) and free thyroxine of 13.6 pmol/l (ref 12-22 pmol/l) which had been 66.8 pmol/l three months prior. TSH receptor antibody was positive- 14.4IU/l(ref <1.8IU/l). She was diagnosed with neutropenic sepsis and agranulocytosis secondary to carbimazole. She was treated with antibiotics and granulocyte colony stimulating factor (GCSF) 30mu once daily as per haematology advice. Thyroid ultrasound showed ‘diffuse thyroid enlargement with increased vascularity in keeping with thyroiditis’ and technetium 99m pertechnetate scan showed ‘high uptake of radionuclide in both lobes, appearances suggest graves’. Her white cell count returned to normal and GCSF was stopped after 6 days. Her thyroid function tests deteriorated while she was off carbimazole: She was commenced on lithium 200 mg bd and discharged home with close outpatient follow up to monitor thyroid function tests and lithium levels. Unfortunately, she did not attend her follow up appointments and was poorly compliant with lithium therapy. When she engaged with the service again, she had clinical and biochemical evidence of thyrotoxicosis with a free thyroxine of 80 pmol/l and evidence of thyroid eye disease with left eye proptosis, lid retraction and exophthalmos and mild right eye proptosis. Lithium therapy was restarted and a plan was made for definitive therapy. Surgery was preferred over radioactive iodine treatment given the presence of thyroid eye disease and the patient’s plans for pregnancy in the near future. She was electively admitted prior to surgery for treatment with lugol’s iodine and close monitoring of thyroid function tests. She ultimately had a successful thyroidectomy and is now well on thyroxine replacement therapy.