Clinical data: A 47-year-old woman requested a second opinion. She was treated with hyperthyroidism for 2 months. Methimazole therapy was started but agranulocytosis had developed. Radioiodine therapy was advised in another hospital.

Palpation: diffusely enlarged thyroids.

Result of blood tests: hyperthyroidism with TSH-level 0.001 mIU/L and FT4 41.0 pM/L.

Ultrasonography: A hypoechogenic, inhomogeneous thyroid was found with increased vascularization.

Clinical diagnosis: hyperthyroidism caused by Graves' disease.

We advised surgery. The patient was treated with Lugol's solution starting with daily 3x5 drips and increasing with daily 3x1 drips. The blood test was rechecked 9 days later, and resulted in normal FT4 levels. She underwent surgery the next day.

Histopathology: diffuse goiter corresponding to Graves' disease.

Comment: Agranulocytosis is the most severe complication of thyrostatic therapy. In most patients, the isolation and the combined antibiotic therapy results in complete recovery within 2 to 3 days. This happened in this patient, too. To change one thyrostatic drug to another one is not acceptable considering the possibility of cross-allergy in the event of agranulocytosis.
If the FT4 level is already significantly elevated when agranulocytosis develops, we do not administer radioiodine, because the transient further elevation of thyroid hormone levels after this therapy may cause serious cardiac problems. On the other hand, the presurgery treatment with increasing dose of Lugol's solution results in euthyroidism within a several days and thereafter the patient can be operated without any risk.

 

 

 

 

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