Thyrotoxicosis and collagen-like disease in three sisters of American Indian extraction

The Pharmacotherapy of Thyroid Storm

A review of thyrotoxic storm is presented. Included are causes, symptomatology, and mortality rates. Special emphasis is placed on the strong correlation between adrenergic blockade and success rates in treating thyrotoxic storm. Pharmacotherapy of the acute storm patient is discussed in detail with respect to agents that (1) decrease production of thyroid hormones; (2) block release of preformed thyroid hormones from the gland; (3) blunt the effects of excess thyroid hormones on the various target organs (e.g., CNS and heart); and (4) serve to decrease the metabolic strain on all organ systems caused by thyrotoxic storm.

ANCA-associated vasculitis and lupus-like syndrome caused by methimazole

A 24-year-old woman with Graves' disease treated with methimazole for 4 years, developed recalcitrant ulcers on the lower legs. Histological studies demonstrated vasculitis in deep dermal vessels accompanied by C3 deposition. Laboratory investigation revealed lupus-like abnormalities (leucocytopenia, positive antinuclear and antidouble strand (ds) DNA antibodies, and positive ANCA). The leg ulcers dramatically improved after methimazole was withdrawn. In addition, leucocytopenia and the immunological abnormalities soon faded. Although lupus-like syndrome is well known to be induced by antithyroid drugs, vasculitis is a rare complication. To the best of our knowledge, this is the first report describing ANCA-associated vasculitis caused by methimazole.

Lupus erythematosus-like syndrome induced by thiamazole and propylthiouracil

A 17-year-old Japanese woman developed a lupus erythematosus-like syndrome during treatment for Graves' disease with thiamazole and propylthiouracil. Erythema, arthralgia, and low grade fever developed during therapy with thiamazole; purplish-red erythema developed during therapy with propylthiouracil. Antinuclear antibodies, anti-single-stranded DNA antibodies, and anti-double-stranded DNA antibodies were positive throughout the administration of these two drugs. Eruptions and other symptoms improved after their discontinuation. The titers of autoantibodies also decreased two months after withdrawal. The patient had HLA DR4.

Hyperthyroidism in identical adolescent male twins

Monozygous adolescent male twins with hyperthyroidism are presented. One twin had associated thyroiditis. The other twin presented with muscle weakness and paralysis. Treatment was successful with antithyroid medication and levothyroxine.

Systemic lupus erythematosus and thyrotoxicosis: a hitherto little recognised association

Six patients are reported in whom systemic lupus erythematosus (SLE) and thyrotoxicosis coexisted. All had four or more American Rheumatism Association criteria (1982) for the diagnosis of SLE and had clinical manifestations and function test results characteristic of hyperthyroidism (except for one who had been thyroidectomised previously). In three patients the diagnosis of hyperthyroidism preceded that of SLE, in two patients both diseases began simultaneously, and only in one was the diagnosis of thyrotoxicosis made after that of SLE. It is suggested that hyperthyroidism associated with SLE may be a form of presentation of thyroiditis. This association may pass unnoticed because of the similarity of some clinical manifestations.

Which anti-thyroid drug?

Anti-thyroid drugs are widely used to treat diffuse toxic goiter (Graves' disease). Of the two drugs currently available in the United States, propylthiouracil is prescribed far more often than is methimazole (Tapazole). However, compared with propylthiouracil, methimazole can be given as a single daily dose, is cheaper, and, at low doses, is associated with less major toxicity; for these reasons, methimazole should be used for the routine management of Graves' disease when anti-thyroid drugs are selected as primary therapy. On the other hand, because of certain pharmacologic factors, propylthiouracil should be used in selected situations, particularly in patients with "thyroid storm" and in pregnant or lactating women.

Graves' disease with neutropenia and marked splenomegaly: autoimmune neutropenia due to propylthiouracil

A 38-year-old man with Graves' disease taking propylthiouracil (PTU) for 6 years developed neutropenia and marked splenomegaly. After subtotal thyroidectomy with discontinuance of PTU the patient remained asymptomatic for the last two and half years. The serum obtained during the period of neutropenia demonstrated opsonic activity to neutrophils of the patient as well as of normal volunteers. This opsonic antineutrophil activity was located in the IgG fraction of the serum. Furthermore, PTU at the concentration (0.1-1.0 micrograms/ml) attainable in the patient's serum significantly stimulated [3H] thymidine incorporation in the patient's lymphocytes. These findings indicate that the patient developed autoimmune neutropenia by producing opsonic antineutrophil antibodies in association with the PTU therapy.

Antithyroid drugs

Over the past four decades, a great deal has been learned about the pharmacology and mechanisms of action of antithyroid drugs. Their ability to inhibit hormone biosynthesis involves complex interactions with thyroid peroxidase and thyroglobulin, many of which are still poorly understood. Their spectrum of activity is much wider than previously thought, and a number of clinically important extrathyroidal actions have been identified. Despite a greater appreciation for the intricacies of antithyroid-drug pharmacology, controversies still surround the use of these agents in the treatment of thyrotoxicosis. These controversies are apt to continue until the pathophysiology of Graves' disease is fully elucidated.

Multiple complications of propylthiouracil treatment: granulocytopenia, eosinophilia, skin reaction and hepatitis with lymphocyte sensitization

An association of granulocytopenia, eosinophilia, skin reaction and hepatitis during propylthiouracil (PTU) therapy for thyrotoxicosis in a 47 year old black female is reported. Clinical and biochemical abnormalities disappeared soon after discontinuation of PTU. That the drug was directly responsible for the observed complications is suggested by the clinical course and by in vitro lymphocyte transformation studies. The latter revealed sensitization to PTU during the acute phase of the disease, which was greatly reduced 5 weeks after discontinuation of the drug and was completely absent after 5 months.