Rapid Preoperative Preparation for Thyroidectomy of a Severely Hyperthyroid Patient with Graves’ Disease who Developed Agranulocytosis
Abstract
Preoperative preparation of the hyperthyroid patient for thyroidectomy is imperative to avoid perioperative complications due to severe thyrotoxicosis. The mainstay of preparation is the administration of anti-thyroid drugs (ATD). When ATDs cause adverse reactions, an alternative regimen to prepare the patient for definitive management is crucial. We present the case of a 35-year-old Filipino female with Graves’ disease who developed methimazole-induced agranulocytosis. She refused to undergo radioactive iodine (RAI) therapy. She was admitted for thyroidectomy with elevated thyroid hormone levels. She was rapidly prepared for thyroidectomy using high-dose steroid, beta-adrenergic blocker, propylthiouracil (PTU) and Lugol’s solution. The patient’s free thyroxine level decreased after 8 days of treatment, without complications. She then underwent an uneventful subtotal thyroidectomy. In conditions with very limited options, although contraindicated, administration of another ATD may be the last alternative for patients who developed agranulocytosis.
Downloads
References
Abraham P, Avenell A, Park CM, et al. A systematic review of drug therapy for Graves’ hyperthyroidism. Eur J Endocrinol. 2005;153(4):489-98. http://dx.doi.org/10.1530/eje.1.01993.
Raboca J, Jimeno C, Kho S, et al for the Philippine Society of Endocrinology and Metabolism (PSEM) PhilTiDeS Working Group. The Philippine Thyroid Disorder Prevalence Study (PhilTiDeS 1): Prevalence of thyroid disorders among adults in the Philippines. J ASEAN Fed Endocr Soc. 2012;27(1):27-33. http://dx.doi.org/10.15605/jafes.027.01.04.
Bahn Chair RS, Burch HB, Cooper DS et al for the American Thyroid Association and American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: Management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011; 21(6):593-646. http://dx.doi.org/10.1089/thy.2010.0417.
Panzer C, Beazley R, Braverman L. Rapid preoperative preparation for severe hyperthyroid Graves’ disease. J Clin Endocrinol Metab. 2004;89(5):2142-4. http://dx.doi.org/10.1210/jc.2003-031981.
Pandey CK, Raza M, Dhiraaj S, et al. Rapid preparation of severe uncontrolled thyrotoxicosis due to Graves’ disease with iopanoic acid - a case report. Can J Anesth.2004;51(1):38-40.
Erbil Y, Ozluk Y, Giriş M, et al. Effect of Lugol’s solution on thyroid gland blood flow and microvessel density in the patients with Graves’ disease. J Clin Endocrinol Metab. 2007;92(6):2182-9.http://dx.doi.org/10.1210/jc.2007-0229.
Zhu JQ, Li ZH, Gong RX, et al. Sequential defunctionalization followed by thyroxine supplementation as preoperative preparation of hyperthyroid patients undergoing thyroidectomy. Chin Med J (Engl). 2008;121(20):2010-5.
Hassan I, Danila R, Aljabri H, et al. Is rapid preparation for thyroidectomy in severe Graves’ disease beneficial? The relationship between clinical and immunohistochemical aspects. Endocrine. 2008;33(2):189-95. http://dx.doi.org/10.1007/s12020-008-9076-8.
Nakamura H, Noh JY, Itoh K, et al. Comparison of methimazole and propylthiouracil in patients with hyperthyroidism caused by Graves’ disease. J Clin Endocrinol Metab. 2007;92(6):2157-62. http://dx.doi.org/10.1210/jc.2006-2135.
Cooper DS. Antithyroid drugs. N Engl J Med. 2005;352(9):905-17. http://dx.doi.org/10.1056/NEJMra042972.
Watanabe N, Narimatsu H, Noh JY, et al. Antithyroid drug-induced hematopoietic damage: A retrospective cohort study of agranulocytosis and pancytopenia involving 50,385 patients with Graves’ disease. J Clin Endocrinol Metab. 2012;97(1):E49-53. http://dx.doi.org/10.1210/jc.2011-2221.
Tajiri J, Noguchi S, Murakami T, et al. Antithyroid drug-induced agranulocytosis: The usefulness of routine white blood cell count monitoring. Arch Intern Med. 1990;150(3):621-4. http://dx.doi.org/ 10.1001/archinte.1990.00390150107020.
Toth EL, Mant MJ, Shivji S, et al. Propylthiouracil-induced agranulocytosis: An unusual presentation and a possible mechanism. Am J Med. 1988;85(5):725-7. http://dx.doi.org/10.1016/S0002-9343(88)80251-1.
Berkman EM, Orlin JB, Wolfsdorf J. An anti-neutrophil antibody associated with a propylthiouracil-induced lupus-like syndrome. Transfusion. 1983;23(2):135-8. http://dx.doi.org/10.1046/j.15372995.1983.23283172851.x.
Fibbe WE, Claas FH, Van der Star-Dijkstra W, et al. Agranulocytosis induced by propylthiouracil: Evidence of a drug dependent antibody reacting with granulocytes, monocytes and haematopoietic progenitor cells. Br J Haematol. 1986;64(2):363-73. http://dx.doi.org/10.1111/j.1365-2141.1986.tb04130.x.
Tsuboi K, Ueshiba H, Shimojo M, et al. The relation of initial methimazole dose to the incidence of methimazole-induced agranulocytosis in patients with Graves’ disease. Endocr J. 2007;54(1):39-43. http://dx.doi.org/10.1507/endocrj.K05-068.
Guffy MM, Goeken NE, Burns CP. Granulocytotoxic antibodies in a patient with propylthiouracil-induced agranulocytosis. Arch Intern Med. 1984;144(8):1687-8.
Henley DE, Kaye JM, Nguyen HH, et al. Rapid preparation of patients with Graves’ hyperthyroidism for urgent thyroidectomy. Intern Med J. 2006;36(1):63-4. http://dx.doi.org/10.1111/j.1445-5994.2005.00988.x.
Ezer A, Caliskan K, Parlakgumus A, et al. Preoperative therapeutic plasma exchange in patients with thyrotoxicosis. J Clin Apher. 2009;24(3):111-4. http://dx.doi.org/10.1002/jca.20200.
Guvenc B, Unsal C, Gurkan E, et al. Plasmapheresis in the treatment of hyperthyroidism associated with agranulocytosis: A case report. J Clin Apher. 2004;19(3):148-50. http://dx.doi.org/10.1002/jca.20014.
Mochinaga N, Eto T, Maekawa Y, et al. Successful preoperative preparation for thyroidectomy in Graves’ disease using lithium alone: Report of two cases. Surg Today. 1994;24(5):464-7.
Tsai WC, Pei D, Wang TF, et al. The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves’ hyperthyroidism. Clin Endocrinol (Oxf). 2005;62(5):521-4. http://dx.doi.org/10.1111/j.1365-2265.2005.02249.x.
Kaykhaei MA, Shams M, Sadegholvad A, et al. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine. 2008;34(1-3):52-5. http://dx.doi.org/10.1007/s12020-008-9107-5.
Solomon BL, Wartofsky L, Burman KD. Adjunctive cholestyramine therapy for thyrotoxicosis. Clin Endocrinol (Oxf). 1993;38(1):39-43. http://dx.doi.org/ 10.1111/j.1365-2265.1993.tb00970.x.
Mercado M, Mendoza-Zubieta V, Bautista-Osorio R, et al. Treatment of hyperthyroidism with a combination of methimazole and cholestyramine. J Clin Endocrinol Metab. 1996;81(9):3191-3. http://dx.doi.org/10.1210/jcem.81.9.8784067.
Sebastián-Ochoa A, Quesada-Charneco M, Fernández-García D, et al. Dramatic response to cholestyramine in a patient with Graves’ disease resistant to conventional therapy. Thyroid. 2008;18(10):1115-7. http://dx.doi.org/10.1089/thy.2008.0094.
Guo Z, Yu P, Liu Z, et al. Total thyroidectomy vs bilateral subtotal thyroidectomy in patients with Graves’ disease: a meta-analysis of randomized clinical trials. Clin Endocrinol (Oxf) 2013;79(5):739-46. http://dx.doi.org/10.1111/cen.12209.
Woeber KA. Update on the management of hyperthyroidism and hypothyroidism. Arch Intern Med 2000;160(8):1067-71. http://dx. doi.org/10.1001/archinte.160.8.1067.
Published
How to Cite
Issue
Section
License
Journal of the ASEAN Federation of Endocrine Societies is licensed under a Creative Commons Attribution-NonCommercial 4.0 International. (full license at this link: http://creativecommons.org/licenses/by-nc/3.0/legalcode).
To obtain permission to translate/reproduce or download articles or use images FOR COMMERCIAL REUSE/BUSINESS PURPOSES from the Journal of the ASEAN Federation of Endocrine Societies, kindly fill in the Permission Request for Use of Copyrighted Material and return as PDF file to jafes@asia.com or jafes.editor@gmail.com.
A written agreement shall be emailed to the requester should permission be granted.
