Hyperthyroidism, not only related to nail work...

Preface

"Headache cure head, foot pain heal foot" is used to describe inexperienced doctors, but there are also patients who have such one-sided ideas

Case after

I found a result like this in my blood routine post:

Figure 1 Patient blood count results

White blood cells so low? Are the results reliable? After smear microscopy, the data is true

Figure 2 Results of blood routines one and a half months ago

Figure 3 Biochemical results one and a half months ago

Figure 4 Results of the first month and a half

Figure 5 Results of 2 thyroid autoantibodies before one and a half months

Patients may have transferred from cardiology to endocrinology after discovering problems with alpha work, and then added TSH receptor antibodies and TPO antibodies

A month ago, the blood routine was reviewed:

Figure 6 Blood routine results one month ago

A week ago, I reviewed the work of the first class:

Figure 7 Results of A Week Ago

It turned out to be a hyperthyroid patient

The patient was immediately admitted to the Generalist Department for treatment, and a series of related examinations and tests

Brief medical history: patient female, 52 years old, 1 month ago in the outpatient clinic diagnosed hyperthyroidism, oral methamidazole, vitamin B1, propranolol treatment, 3 days ago there is no obvious cause of sore throat, fever, up to 39 °, so self-discontinuation, oral "swollen nodular wind dispersible tablets, ibuprofen extended-release capsules", self-induced sore throat relief, but still intermittent fever, so see the doctor

Treatment: Clinical consideration may be that methimazole may cause agranulocytosis

(1) Give the treatment of discontinuation of methimazole, cefazolin anti-infection, ricodon lever leukocytes, human granulocyte stimulating factor lancet granulocytes, ibuprofen suspension drops antipyretic and other treatments; Anticoagulation of natricarin due to fibrinogen as high as critical values, suspected of hypercoagulable blood due to acute infection;

(2) On the second day of hospitalization, considering that the patient is a high-risk group with low immunity, gram-negative bacillus infection is not excluded, and it is changed to cefoperazone sulbactam anti-infection and dexamethasone anti-inflammatory; Abnormal renal function, which may be severe infection, hypoperfusion leading to acute kidney injury, and rehydration support; Atrial fibrillation, which may be associated with hyperthyroidism;

(3) On the third day, coinciding with the patient's menstrual period, the amount of bleeding is large, the natricaridin is discontinued, and the sodium carosulfonium is given to stop the bleeding, but at this time it is in a hypercoagulable state, and the use of hemostatic drugs is afraid of thrombosis risk; After 53 hours of admission, the patient's body is wet and cold, restless, the heart rate is accelerated, the blood pressure cannot be detected, the blood gas return is metabolic acidosis, septic shock is considered, and the patient is transferred to the ICU after consultation;

(4) After the transfer of the department, the tracheal intubation ventilator is given to assist breathing, the central venous catheter, the m-hydroxylamine, norepinephrine boost, the meropenem anti-infection, the esomeprazole inhibitory acid, the human granulocyte stimulating factor proding granulocytes, the hemocoaglutin hemostasis, the hydrocortisone anti-inflammatory; Due to anemia and thrombocytopenia, suspended red blood cells and platelets

(5) Family members request to be transferred to the hospital and are automatically discharged

Diagnosis of discharge: Enterobacter pussica sepsis, acute purulent tonsillitis, agranulocytosis, septic shock, severe anemia, thrombocytopenia, hyperthyroidism, atrial fibrillation

Here are some of the patient's test results:

Fig.

Fig.

Figure 10 Results of the third insidious inpatient

Figure 11 Blood gas results on the third day of hospitalization

Figure 12 Results of the blood routine on the third day of hospitalization (transferred to the ICU)

Figure 13 Blood culture results

Case studies

The patient's experience of only 64 hours of medical treatment was thrilling

Methimazole (tabazole) is a first-line drug for the clinical treatment of hyperthyroidism, which inhibits the coupling of tyrosine in the thyroid gland by inhibiting the synthesis of peroxidase in the thyroid gland, resulting in obstruction of T4 and T3 synthesis, but does not affect the absorption of iodine and the release of synthesized thyroid hormones, and has an immunosuppressive effect, and the effect is exact

Common adverse reactions include mild skin pruritus, rash, and urticaria, and rarely, agranulocytosis, thrombocytopenia, pancytopenia, and cholestatic jaundice[1

Agranulocytosis (absolute value of neutrophils in peripheral blood <0.

Clinical manifestations are fever, sore throat, general malaise, etc.
, and in severe cases, sepsis occurs, and the case fatality rate is high
.
It is recommended to regularly monitor leukocytes during treatment and discontinue the drug
immediately if the neutrophil < 1.
5 × 109/L.
The incidence of toxic liver disease is 0.
1% to 0.
2%, mostly occurring within three weeks after administration, manifesting as allergic hepatitis, with a case fatality rate of up to 25% to 30% [2].
<b12> In this case, agranulocytosis occurred, but there was no significant disruption of liver function, and only bilirubin was mildly elevated
.

Because the half-life of T4 is 7 days, plus the release of thyroid hormone stored in the thyroid gland takes about 2 weeks, antithyroid drugs mostly work after 4 weeks
.
Side effects of the commonly used drug "methioimidazole" are dose-dependent, while "propythionimethiazine" is non-dose-dependent, but they cause an equal incidence of agranulocytosis, about 0.
3%, and there is a 50% cross-reaction
.
Therefore, patients with agranulocytosis caused by one of the drugs should not be continued with another drug, and 131I or surgery may be considered to exclude contraindications [2
].
It has been suggested that methimazole has a greater effect on white blood cells and platelets, while prothiohydrazine affects the liver [3].

In 2018, the former State Food and Drug Administration revised the instructions for methimazole, adding to the "Precautions": It has been reported that about 0.
3% to 0.
6% of cases have agranulocytosis, which can occur
weeks or months after the start of treatment and when treatment is re-treated.
Patients are advised to have their blood routine checked once a week for the first 3 months of treatment and once a month during maintenance therapy
.
If symptoms such as stomatitis, pharyngitis, fever and other symptoms occur, you should see a doctor
immediately.
Liver function should be checked once a month for the first three months of treatment, such as anorexia, nausea, epigastric pain, yellow urine, yellow skin, or sclera, and should be seen immediately [4
].

The mechanism of methimazole granulocytosis is not well understood, it may be: (1) bone marrow cytotoxic effect, selective inhibition of myelogenocyte nucleic acid metabolism, resulting in granulocyte maturation disorders, the degree of granulocytopenia is dose-dependent; (2) Immune damage, the drug as a hapten binds to the granulocyte's own protein or attached protein, stimulates the body to produce antibodies, so that the bone marrow hematopoietic cells are destroyed or maturation is blocked; (3) It is related to genetic differences [5].

Summary

Hyperthyroidism is a common endocrine disease in the clinic, with a prevalence of about 0.
5% [6], and the clinical symptoms mainly include: irritability, palpitations, fatigue, protruding eyes, heat intolerance, weight loss, hyperinflation, etc.
, more women than men [7].

Patients treated with oral medications must follow the doctor's advice to regularly monitor alpha function, blood routine, and liver function
.
Previously, I also saw a patient with hyperthyroidism who was only willing to do nail work tests during the medication and did not pay attention to others, resulting in platelets dropping to 10×109/L
.
He suspected that he was a disease of the blood system and went to a specialized hospital for treatment, but later ruled out the blood disease, which the doctor believed was caused by
antithyroid drugs.

References

[LI Taoying, LI Zhiye, XING Ling, et al.
Retrospective analysis of methimazole agranulocytosis with fever in 13 cases[J].
Drug Evaluation and Analysis of Chinese Hospitals,2019,19(6):755-757.

[2] Compilation Group of "Guidelines for the Diagnosis and Treatment of Thyroid Diseases in China" of the Endocrinology Society of the Chinese Medical Association.
Guidelines for the diagnosis and treatment of thyroid diseases in China-Hyperthyroidism[J].
Chinese Journal of Internal Medicine,2007,46(10):876-882.

LIU Jia.
Comparison of clinical efficacy of methimazole and propyl thiouracil in the treatment of hyperthyroidism[J].
China Minkang Medicine,2018,30(5):50-51.

[4] Li Lan, Xia Dongsheng, Tian Chunhua, et al.
Analysis and reflection on the safety risks of methimazole tablets[J].
Chinese Journal of Pharmacovigilance,2018,15(7):393-397.
DOI：10.
3969/j.
issn.
1672-8629.
2018.
07.
003.

Liu Baoying,Jiang Guanyiqing,Liang Ganxiong.
Clinical data analysis of 46 cases of antithyroid drug granulocyte deficiency[J].
Jilin Medicine,2021,42(6):1401-1403.

[6] Peng Lili, Liu Wei, Tang Ren, et al.
Literature analysis of adverse drug reactions/events of methamidazole[J].
Chinese Pharmacovigilance,2018,07:404-410.

Zeng Baimei,Yuan Ling,Lin Shide.
Research progress on liver damage caused by methimazole[J].
Hainan Medicine,2018,29(24):3530-3533.