Thyroidectomy for the treatment of Graves' thyrotoxicosis in thioamide-induced agranulocytosis and sepsis

A Patient with Fulminant Myasthenia Gravis Is Seropositive for Both AChR and LRP4 Antibodies, Complicated by Autoimmune Polyglandular Syndrome Type 3

This article describes the first reported case of myasthenia gravis (MG) seropositive for both acetylcholine receptor antibody and low-density lipoprotein receptor-related protein 4 antibody, complicated by autoimmune polyglandular syndrome (APS) type 3. The patient exhibited myasthenic weakness restricted to the ocular muscles and ptosis. Severe clinical deterioration ensued with predominant bulbar symptoms. MG rapidly worsened, the patient was intubated, and agranulocytosis due to thiamazole was also present, so it was necessary to perform thyroidectomy with tracheostomy and thymectomy in two phases. Both the double-seropositive MG and the APS were involved in the patient's rapid deterioration.

METHIMAZOLE-INDUCED AGRANULOCYTOSIS AND SEPSIS: WAS THYROID STORM PRESENT OR JUST BEING MIMICKED?

Introduction

Agranulocytosis induced by thioamides is rare, occurring only in 0.2-0.5% of cases.

Case presentation

We present the case of a 45-year-old woman previously diagnosed with Graves' disease that discontinued the use of methimazole on her own. She attended the Emergency Department presenting fever (40.5¯C), agitation and diaphoresis. A thyroid storm diagnosis was initially thought, but after laboratory results showing neutrophil count near 0.06x109/L, sepsis due to neutropenia seemed the most logical hypothesis. Cephepime was promptly initiated. For thyrotoxicosis management, cholestyramine and atenolol were prescribed. In her second day of hospitalization, subcutaneous granulocyte colony-stimulating factor was started for an earlier medullar response. The patient was discharged after 7 days with atenolol 50mg/day and instructed to have a definite treatment for Graves disease as soon as possible.

Conclusion

Such case purpose is to remember clinicians that sepsis diagnosis can be challenged, especially when a thyroid storm is a possible diagnosis as well. In this particular case, both conditions should be treated, but life-threatening sepsis should have the focus for a quick therapeutic approach.