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Shale WT, Umer KM, Tola GG, Guluju FA. Asymptomatic Propylthiouracil Induced Agranulocytosis in a Patient with Toxic Nodular Goiter: A Rare Case Report. Int Med Case Rep J 2023; 16:503-512. [PMID: 37701536 PMCID: PMC10493100 DOI: 10.2147/imcrj.s424053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
Background Agranulocytosis is a rare but fatal side effect of antithyroid drugs (ATDs) with incidence reported at 0.1%-1%. Agranulocytosis is defined as a granulocyte count <500 cells/μL following the use of ATDs and is an absolute contraindication to the use of these drugs; in this case, radioactive iodine (RAI) or surgery are therapeutic options. Case Presentation A 28-year-old female patient was on follow-up at our clinic after she presented with anterior neck swelling of 4 years. The patient was started on propylthiouracil (PTU) and propranolol based on clinical symptoms of hyperthyroidism and low thyroid stimulating hormone (TSH) levels. After taking the ATDs for 7 months, she came to the clinic for her regular follow-up. At this point, she was declared euthyroid and booked for surgery. Investigations were sent and the complete blood count (CBC) result showed leucopenia with agranulocytosis, even though she was completely asymptomatic. The offending ATD was immediately discontinued. The patient was kept inpatient for monitoring, and lugol's iodine and propranolol were initiated. Eight days after discontinuing the ATD, the CBC profile was determined once again, showing normalized total leukocyte, as well as, absolute neutrophil count. Eventually, the multinodular goiter (MNG) was managed with subtotal thyroidectomy. Conclusion Despite the fact that agranulocytosis is an extremely rare side effect of ATDs, most often PTU; it is a potentially fatal complication when it occurs. Patient education at the time of prescription should not be overlooked, and systematic programs should be put in place. The baseline granulocyte count should be determined and monitored on a regular basis.
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Affiliation(s)
- Wongel Tena Shale
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Keno Mohammed Umer
- Department of General Surgery, Dire Dawa University, Dire Dawa, Ethiopia
| | - Gutu Ganati Tola
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Fayera Abetu Guluju
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
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2
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Khine A, Dhillon K, Jo L, Wormser V, Naing S, Mishra S. Two Cases of Methimazole-Induced Agranulocytosis With Their Risk Factors. AACE Clin Case Rep 2021; 8:82-84. [PMID: 35415227 PMCID: PMC8984507 DOI: 10.1016/j.aace.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 01/22/2023] Open
Abstract
Background Antithyroid drugs, such as methimazole (MMI), are standard therapies for the medical management of thyrotoxicosis. Agranulocytosis is a rare but lethal adverse effect of antithyroid medications. We have reported 2 cases of MMI-induced agranulocytosis with similar risk factors that likely predisposed them to this adverse reaction. Case Report Case 1 involved a 71-year-old woman, with a history of Graves disease, who presented with an altered mental status. She was recently discharged on 40 mg of MMI twice daily, and she continued this dose for 2 months. She was readmitted and found to have neutropenic fever in the setting of MMI-induced agranulocytosis. MMI was discontinued, and she was started on filgrastim. Her cell counts gradually improved, and she was subsequently discharged. Case 2 involved a 68-year-old woman, with a history of Graves disease, who presented with severe back pain, nausea, and vomiting. She was recently discharged on 10 mg of MMI twice daily, which was increased to 10 mg 3 times a day. She was readmitted to the hospital because of a septic shock in the setting of pneumonia, colitis, bacteremia, and MMI-induced agranulocytosis. A bone marrow biopsy showed a polyclonal infiltrate with up to 85% plasma cells. Despite treatment with antibiotics, filgrastim, and continuous renal replacement therapy, she ultimately passed away. Discussion Although these cases had differing outcomes, they shared similar features and risk factors, including older age, female sex, and relatively higher doses of MMI. Conclusion Close follow up and awareness of risk factors, such as age, female sex, and higher doses of MMI, may decrease the risk of MMI-induced agranulocytosis and fatal outcomes.
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Affiliation(s)
- Aye Khine
- Department of Internal Medicine, University of California San Francisco-Fresno, Fresno, California
- Address correspondence to Dr Aye Khine, MD, UCSF Fresno Medical Education Program, Internal Medicine, 155 N Fresno St., Fresno, CA 93701
| | - Kiranjit Dhillon
- Department of Internal Medicine, University of California San Francisco-Fresno, Fresno, California
| | - Linda Jo
- Department of Internal Medicine, University of California San Francisco-Fresno, Fresno, California
| | - Vanessa Wormser
- Department of Internal Medicine, University of California San Francisco-Fresno, Fresno, California
| | - Soe Naing
- Department of Medicine, Division of Endocrinology, University of California San Francisco-Fresno, Fresno, California
| | - Shreela Mishra
- Department of Medicine, Division of Endocrinology, University of California San Francisco-Fresno, Fresno, California
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3
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Andrès E, Lorenzo Villalba N, Zulfiqar AA, Serraj K, Gottenberg JE. Biotherapies-induced neutropenia in autoimmune and auto-inflammatory disorders and other orphan diseases. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1663172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Emmanuel Andrès
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, Strasbourg, France
| | - Noel Lorenzo Villalba
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, Strasbourg, France
| | - Abrar-Ahmad Zulfiqar
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, Strasbourg, France
| | - Khalid Serraj
- Departments of Internal Medicine, University Hospital of Oujda, Oujda, Morocco
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Andrès E, Villalba NL, Zulfiqar AA, Serraj K, Mourot-Cottet R, Gottenberg AJE. State of Art of Idiosyncratic Drug-Induced Neutropenia or Agranulocytosis, with a Focus on Biotherapies. J Clin Med 2019; 8:E1351. [PMID: 31480527 PMCID: PMC6788182 DOI: 10.3390/jcm8091351] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Idiosyncratic drug-induced neutropenia and agranulocytosis is seldom discussed in the literature, especially for new drugs such as biotherapies outside the context of oncology. In the present paper, we report and discuss the clinical data and management of this relatively rare disorder, with a focus on biotherapies used in autoimmune and auto-inflammatory diseases. MATERIALS AND METHODS A review of the literature was carried out using the PubMed database of the US National Library of Medicine. We searched for articles published between January 2010 and May 2019 using the following key words or associations: "drug-induced neutropenia", "drug-induced agranulocytosis", and "idiosyncratic agranulocytosis". We included specific searches on several biotherapies used outside the context of oncology, including: tumor necrosis factor (TNF)-alpha inhibitors, anti-CD20 agents, anti-C52 agents, interleukin (IL) 6 inhibitors, IL 1 inhibitors, and B-cell activating factor inhibitor. RESULTS Idiosyncratic neutropenia remains a potentially serious adverse event due to the frequency of severe sepsis with severe deep tissue infections (e.g., pneumonia), septicemia, and septic shock in approximately two-thirds of all hospitalized patients with grade 3 or 4 neutropenia (neutrophil count (NC) ≤ 0.5 × 109/L and ≤ 0.1 × 109/L, respectively). Over the last 20 years, several drugs have been strongly associated with the occurrence of idiosyncratic neutropenia, including antithyroid drugs, ticlopidine, clozapine, sulfasalazine, antibiotics such as trimethoprim-sulfamethoxazole, and deferiprone. Transient grade 1-2 neutropenia (absolute blood NC between 1.5 and 0.5 × 109/L) related to biotherapy is relatively common with these drugs. An approximate 10% prevalence of such neutropenia has been reported with several of these biotherapies (e.g., TNF-alpha inhibitors, IL6 inhibitors, and anti-CD52 agents). Grade 3-4 neutropenia or agranulocytosis and clinical manifestations related to sepsis are less common, with only a few case reports to date for most biotherapies. Special mention should be made of late onset and potentially severe neutropenia, especially following anti-CD52 agent therapy. During drug therapy, several prognostic factors have been identified that may be helpful when identifying 'susceptible' patients. Older age (>65 years), septicemia or shock, renal failure, and a neutrophil count ≤0.1 × 109/L have been identified as poor prognostic factors. Idiosyncratic neutropenia should be managed depending on clinical severity, with permanent/transient discontinuation or a lower dose of the drug, switching from one drug to another of the same or another class, broad-spectrum antibiotics in cases of sepsis, and hematopoietic growth factors (particularly G-CSF). CONCLUSION Significant progress has been made in recent years in the field of idiosyncratic drug-induced neutropenia, leading to an improvement in their prognosis (currently, mortality rate between 5 and 10%). Clinicians must continue their efforts to improve their knowledge of these adverse events with new drugs as biotherapies.
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Affiliation(s)
- Emmanuel Andrès
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France.
| | - Noel Lorenzo Villalba
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France
| | - Abrar-Ahmad Zulfiqar
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France
| | - Khalid Serraj
- Departments of Internal Medicine, University Hospital of Oujda, 59000 Oujda, Morocco
| | - Rachel Mourot-Cottet
- Department of Internal Medicine, Medical Clinic B, University Hospital of Strasbourg, 67084 Strasbourg, France
| | - And Jacques-Eric Gottenberg
- Department of Rheumatology, University Hospital of Strasbourg, 67084 Strasbourg, France
- Referral Center of Immune Cytopenias, University Hospital of Strasbourg, 67084 Strasbourg, France
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Rabelo PN, Rabelo PN, Paula AFD, Conceição SAD, Viggiano DPPDO, Antunes DE, Jatene EM, Paula SLFMD, Dias ML, Reis MAL. Propylthiouracil-induced agranulocytosis as a rare complication of antithyroid drugs in a patient with Graves' disease. Rev Assoc Med Bras (1992) 2019; 65:755-760. [PMID: 31340298 DOI: 10.1590/1806-9282.65.6.755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/24/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder characterized by hyperthyroidism. Antithyroid drugs (ATDs) are available as therapy. Agranulocytosis is a rare but potentially fatal complication of this therapy. In this study, we report agranulocytosis induced by propylthiouracil (PTU) in a patient with GD and the difficulties of clinical management. CASE RNBA, male, 30 years old, with GD, treated with propylthiouracil (PTU). He progressed with pharyngotonsillitis. Then, PTU was suspended and antibiotic, filgrastim, propranolol, and prednisone were initiated. Due to the decompensation of hyperthyroidism, lithium carbonate, dexamethasone, and Lugol's solution were introduced. Total thyroidectomy (TT) was performed with satisfactory postoperative progression. DISCUSSION We describe here the case of a young male patient with GD. For the treatment of hyperthyroidism, thioamides are effective options. Agranulocytosis induced by ATDs is a rare complication defined as the occurrence of a granulocyte count <500/mm3 after the use of ATDs. PTU was suspended, and filgrastim and antibiotics were prescribed. Radioiodine (RAI) or surgery are therapeutic alternatives. Due to problems with ATD use, a total thyroidectomy was proposed. The preoperative preparation was performed with beta-blocker, glucocorticoid, lithium carbonate, and Lugol solution. Cholestyramine is also an option for controlling hyperthyroidism. TT was performed without postoperative complications. CONCLUSION Thionamide-induced agranulocytosis is a rare complication. With a contraindication to ATDs, RAI and surgery are definitive therapeutic options in GD. Beta-blockers, glucocorticoids, lithium carbonate, iodine, and cholestyramine may be an adjunctive therapy for hyperthyroidism.
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Affiliation(s)
- Patrícia Novais Rabelo
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Paula Novais Rabelo
- Faculty of Nutrition. Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Allyne Fernanda de Paula
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Samuel Amanso da Conceição
- Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | | | - Daniela Espíndola Antunes
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Estela Muszkat Jatene
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Sílvia Leda França Moura de Paula
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Monike Lourenço Dias
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
| | - Maria Aparecida Lopes Reis
- Division of Endocrinology & Metabolism, Intern Medicine Department, Hospital das Clínicas, Faculty of Medicine, Federal University of Goiás (HC-UFG), Goiás, GO, Brasil
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Hongo T, Nozaki S, Tsuchiya M, Inaba M, Takahashi K, Fujiwara T. Contrast medium-induced transient severe leukopenia. Acute Med Surg 2018; 5:185-188. [PMID: 29657733 PMCID: PMC5891103 DOI: 10.1002/ams2.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/21/2017] [Indexed: 11/07/2022] Open
Abstract
Case Contrast medium-induced transient leukopenia is very rare. Here, we report a case of a 73-year-old man diagnosed with contrast media-induced transient leukopenia. The patient underwent abdominal contrast-enhanced computed tomography, where he was given non-ionic iodinated contrast medium i.v. His medical history included an allergic reaction to a different contrast medium. One hour later, the patient was admitted to the emergency department complaining of chest discomfort. He had leukopenia and a fever (temperature of 38.9°C). Complete blood count showed a white blood cell count of 930/μL and an absolute neutrophilic count of 232/μL. Outcome The patient was given i.v. antibiotics and 5 mg chlorpheniramine maleic acid, 20 mg famotidine, and 125 mg methylprednisolone. The patient's white blood cell count recovered the next day, and he was discharged after 2 days of hospitalization. Conclusion We diagnosed the patient with contrast media-induced transient leukopenia, which is a rare phenomenon.
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Affiliation(s)
- Takashi Hongo
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Satoshi Nozaki
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Midori Tsuchiya
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Mototaka Inaba
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
| | - Kenji Takahashi
- Emergency Department Okayama Saiseikai General Hospital Okayama Japan
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Bukhari S, Khan M, Kumar N, Mohan V. Increased risk for thionamide-induced agranulocytosis in elderly patients: a case presentation and literature review. BMJ Case Rep 2017; 2017:bcr-2017-220924. [PMID: 28716776 DOI: 10.1136/bcr-2017-220924] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thionamides, such as methimazole and propylthiouracil, are used for the management of hyperthyroidism. Agranulocytosis is a rare adverse effect of thionamides and elderly patients are especially vulnerable. Here we discuss a case of an 80-year-old woman who developed agranulocytosis and pneumonia approximately 4 weeks after starting low dose methimazole therapy. Despite aggressive treatment with broad-spectrum antibiotics and granulocyte colony stimulating factor, she developed multiorgan failure and died. Our goals are to identify risk factors common to elderly patients and hopefully improve outcomes in this population when prescribed thionamides.
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Affiliation(s)
- Sumera Bukhari
- Department of Internal Medicine, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
| | - Muhammad Khan
- Department of Internal Medicine, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
| | - Naresh Kumar
- Department of Internal Medicine, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
| | - Vinuta Mohan
- Department of Endocrinology, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
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