Therapeutic plasma exchange (TPE) is one possible treatment for patients resistant to conventional antithyroid drugs or requiring urgent attention for thyrotoxicosis. We report a 35-yr-old man with thyrotoxicosis, ultimately attributed to Graves' disease in whom antithyroid drug used initially was soon discontinued, due to abnormal liver function, and replaced by Lugol's solution. Three weeks later, an escape phenomenon (to Lugol's solution) was apparent, so we performed TPE to control the thyrotoxicosis. Two courses of TPE by a centrifugal type machine resulted in diminished levels of thyroid hormone levels, which then rebounded after another two courses of membrane filtration type TPE. However, the patient could be treated with radioactive iodine therapy without any complications at present.
Adult ; Antithyroid Agents/adverse effects/therapeutic use ; Cetirizine/adverse effects/therapeutic use ; Graves Disease/*radiotherapy ; Hepatitis B, Chronic/complications ; Humans ; Iodides/therapeutic use ; Iodine Radioisotopes/*therapeutic use ; Male ; Methimazole/adverse effects/therapeutic use ; Plasmapheresis/*methods ; Thyroid Gland/*pathology ; Thyrotoxicosis/*therapy

OBJECTIVEPropylthiouracil (PTU) as a drug used during the treatment of hyperthyroidism could induce antineutrophil cytoplasmic autoantibody-positive vasculitis. Here the author reported a childhood case of antineutrophil cytoplasmic autoantibody-positive vasculitis induced by PTU, which is rarely described.

METHODSThe diagnosis was made according to the symptoms, signs, serum markers and renal biopsy, and the relevant literature was reviewed.

RESULTSThe 12-year-old girl presented with gross hematuria, proteinuria, renal function damage [Ccr 52.46 ml/(min. 1.73 m(2))], positive antineutrophil cytoplasmic autoantibody (ANCA-MPO) (MPO ELISA 140%) and a vasculitis lesion in the renal biopsy sample. She had been treated with PTU for 5 years because of Graves disease. After the diagnosis, the PTU was withdrawn, and prednisone (40 mg/d) and cyclophosphamide (25 mg, Bid) were applied. Three weeks after the therapy with prednisone and cyclophosphamide the gross hematuria disappeared. Three months after the treatment the renal function returned to normal [Ccr 124 mg/(min.1.73 m(2))], and the titer of ANCA-MPO decreased from 140% to 57%.

CONCLUSIONPTU may induce antineutrophil cytoplasmic autoantibody positive vasculitis. A right diagnosis and treatment can improve its prognosis of the disease.

Antibodies, Antineutrophil Cytoplasmic ; blood ; Antithyroid Agents ; adverse effects ; therapeutic use ; Child ; Diagnosis, Differential ; Female ; Humans ; Hyperthyroidism ; drug therapy ; Prognosis ; Propylthiouracil ; adverse effects ; therapeutic use ; Treatment Outcome ; Vasculitis ; chemically induced ; diagnosis ; therapy

OBJECTIVETo study the relationship between methimazole (MMI) and antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis.

METHODSThirty-three cases with Graves' disease were tested for serum ANCA before and after taking MMI. At the same time, clinicopathological data of two patients with Graves' disease who had antineutrophil cytoplasmic antibody-positive vasculitis during treatment with MMI were analyzed.

RESULTSTwo patients developed antineutrophil cytoplasmic antibody-positive vasculitis during the medication with MMI for 5-6 years; their major clinical manifestations were hematuria and renal failure. Renal biology showed renal vasculitis and vascular necrosis. The disease was relieved after treatment with immunosuppressor. Serum ANCA in the 33 cases was negative before taking MMI. In 3 cases serum ANCA became positive after taking MMI for 2 months, 3 months and 2 years, respectively. The positive rate is 9% (3/33). The major finding was microscopic hematuria. ANCA positive rate was significantly higher after taking MMI than that before taking MMI (chi2) = 5.3, P < 0.05). Microscopic hematuria disappeared after general treatment.

CONCLUSIONThere may be a relationship between methimazole and development of antineutrophil cytoplasmic antibody-positive vasculitis. Renal impairment can occur. The signs and symptoms of the vasculitis can disappear after proper treatment.

Adolescent ; Antibodies, Antineutrophil Cytoplasmic ; blood ; Antithyroid Agents ; adverse effects ; therapeutic use ; Child ; Female ; Graves Disease ; drug therapy ; pathology ; Humans ; Kidney ; pathology ; Male ; Methimazole ; adverse effects ; therapeutic use ; Vasculitis ; chemically induced

Methimazole and propylthiouracil have been used in the management of hyperthyroidism for more than half a century. However, hepatotoxicity is one of the most deleterious side effects associated with these medications. The mechanism(s) of hepatic injury induced by antithyroid agents is not fully recognized yet. Furthermore, there are no specific tools for predicting the occurrence of hepatotoxicity induced by these drugs. The purpose of this article is to give an overview on possible susceptibility factors in liver injury induced by antithyroid agents. Age, gender, metabolism characteristics, alcohol consumption, underlying diseases, immunologic mechanisms, and drug interactions are involved in enhancing antithyroid drugs-induced hepatic damage. An outline on the clinically used treatments for antithyroid drugs-induced hepatotoxicity and the potential therapeutic strategies found to be effective against this complication are also discussed.
Animals ; Antithyroid Agents/*adverse effects/chemistry/therapeutic use ; Disease Models, Animal ; Drug-Induced Liver Injury/drug therapy/*etiology ; Graves Disease/drug therapy ; Humans ; Hyperthyroidism/drug therapy ; Protective Agents/therapeutic use ; Reactive Oxygen Species/metabolism ; Risk Factors

Bullous systemic lupus erythematosus (SLE) is a kind of LE-non-specific bullous skin disease that is rarely induced by a medication. We describe the first case of bullous SLE to develop after administration of methimazole. A 31-yr-old woman presented with generalized erythematous patches, multiple bullae, arthralgia, fever, conjunctivitis, and hemolytic anemia. Biopsy of her bulla showed linear deposition of lgG, lgA, C3, fibrinogen, and C1q at dermo-epidermal junction. She was diagnosed as bullous SLE and treated with prednisolone, dapsone, hydroxychloroquine, and methotrexate. Our experience suggests that SLE should be considered as a differential diagnosis when bullous skin lesions develop in patients being treated for hyperthyroidism.
Adult ; Anti-Inflammatory Agents/therapeutic use ; Antirheumatic Agents/therapeutic use ; Antithyroid Agents/*adverse effects/therapeutic use ; Blister/chemically induced/pathology ; Drug Therapy, Combination ; Female ; Graves Disease/diagnosis/drug therapy ; Humans ; Hydroxychloroquine/therapeutic use ; Immunosuppressive Agents/therapeutic use ; Lupus Erythematosus, Systemic/chemically induced/*diagnosis/drug therapy ; Lupus Nephritis/diagnosis/drug therapy ; Methimazole/*adverse effects/therapeutic use ; Mycophenolic Acid/analogs & derivatives/therapeutic use ; Prednisolone/therapeutic use ; Skin/pathology

Both Graves disease and Guillain-Barre syndrome (GBS) are autoimmune disorders caused by impaired self-tolerance mechanisms and triggered by interactions between genetic and environmental factors. GBS in patients who suffer from other autoimmune diseases is rarely reported, and the development of postinfectious GBS in a patient with Graves disease has not been previously reported in the literature. Herein, we report a patient with Graves disease who developed postinfectious GBS during a course of methimazole-induced agranulocytosis.
Agranulocytosis/*chemically induced/diagnosis/therapy ; Antithyroid Agents/*adverse effects ; Female ; Graves Disease/diagnosis/*drug therapy ; Guillain-Barre Syndrome/diagnosis/*etiology/therapy ; Humans ; Immunoglobulins, Intravenous/therapeutic use ; Methimazole/*adverse effects ; Middle Aged ; Opportunistic Infections/diagnosis/*etiology/therapy ; Thyroidectomy ; Treatment Outcome

Adolescent ; Adult ; Aged ; Antithyroid Agents ; administration & dosage ; adverse effects ; therapeutic use ; Biomarkers ; blood ; Female ; Hepatitis B ; complications ; pathology ; Hepatitis, Viral, Human ; complications ; pathology ; Humans ; Hyperthyroidism ; complications ; drug therapy ; Liver Function Tests ; Male ; Methimazole ; administration & dosage ; adverse effects ; therapeutic use ; Middle Aged ; Propylthiouracil ; administration & dosage ; adverse effects ; therapeutic use ; Retrospective Studies ; Severity of Illness Index ; Thyroid Function Tests ; Young Adult

OBJECTIVETo study the incidence, clinical features and related factors of propylthiouracil (PTU)-induced hepatic injury in patients with hyperthyroidism.

METHODSA prospective study were carried out in 70 patients of hyperthyroidism with normal liver function. Every patient was treated with PTU 300 mg/d until the thyroid functions recovered to normal, following by decease and maintenance PTU dose in period of six months. Liver function, including serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), total bilirubin (TBIL) and direct bilirubin (DBIL), thyroid function (serum thyroxine, triiodothyronine, free thyroxine, and free triiodothyronine and thyrotropin) and blood routine items were measured before therapy and once a month for six months after PTU therapy was begun.

RESULTSSixty-four cases of 70 patients completed the therapy for 6 months. Hepatic injury developed in 33 patients (51.6%). Asymptomatic, transient hepatic injury was shown in 22 patients (34.4%). Slight symptomatic hepatic injury occured in 6 cases (9.4%) and overt hepatic injury in 5 patients (7.8%) after PTU administration. However, all the patients who developed overt hepatic injury did not stop PTU. Hepatic function returned normal one month after stopping PTU. No one finally suffered from viral hepatitis and autoimmune hepatitis in patients of symptomatic and overt hepatic injury.

CONCLUSIONSPTU-induced symptomatic hepatic injury is not rare and usually develops within the first few months of PTU administration. Its clinical course is relatively benign. However, it may be difficult to predict its development, so all patients should be monitored for liver function test during the administration in early stage.

Adolescent ; Adult ; Aged ; Antithyroid Agents ; adverse effects ; therapeutic use ; Chemical and Drug Induced Liver Injury ; Female ; Follow-Up Studies ; Humans ; Hyperthyroidism ; drug therapy ; Liver ; pathology ; physiopathology ; Liver Diseases ; physiopathology ; Liver Function Tests ; Male ; Middle Aged ; Propylthiouracil ; adverse effects ; therapeutic use ; Prospective Studies

Propylthiouracil (PTU) is known to be a potential cause of antineutrophil cytoplasmic antibody (ANCA) positive small vessel vasculitis, resulting in glomerulonephritis and diffuse alveolar hemorrhage (DAH). Herein, we describe a 25-year-old pregnant woman who developed a perinulcear ANCA (p-ANCA) and myeloperoxidase ANCA (MPO-ANCA) positive DAH during PTU therapy. The patient improved after corticosteroid therapy and discontinuation of the PTU. Methimazole was prescribed in spite of the risk of recurrence of DAH because of the pregnancy. The patient is currently free from pulmonary problems. Our case shows that the alternative agent, methimazole, can be used to treat hyperthyroidism in a pregnant patient with PTU associated DAH.
Tomography, X-Ray Computed ; *Pulmonary Alveoli ; Propylthiouracil/*adverse effects/therapeutic use ; *Pregnancy Complications, Hematologic ; Pregnancy ; Hyperthyroidism/blood/complications/*drug therapy ; Humans ; Hemoptysis/*chemically induced/diagnosis/immunology ; Female ; Diagnosis, Differential ; Bronchoscopy ; Antithyroid Agents/*adverse effects/therapeutic use ; Antibodies, Antineutrophil Cytoplasmic/*blood ; Adult

OBJECTIVETo comprehensively evaluate the treatment of Graves' disease in children with (131)I and antithyroid drugs (ATD) and to quantitatively assess the advantages and disadvantages of them.

METHODSThe authors examined the outcome of (131)I and ATD treatment in children with Graves' disease at the Hospital of Dongshan District in Guangzhou during the period 1997 to 2002. Each of the 2 groups of patients consisted of 40 patients ranging in age from 8 to 14 years (mean 10.7 +/- 2.2). The groups were similar in age, gender, length of disease, goiter size, and initial serum thyroid hormone levels. Thyroid status was assessed > 2 year after the therapies started. The efficacy of the therapeutic methods were scored as follows: the children whose disease was cured were marked 0, and those who had improvement but were not cured were marked 1, and those who remained unchanged were marked 2. After treatment the patients who were demonstrated to have ophthalmopathy or more severe ophthalmopathy, hyperthyroid heart disease, liver function damage and leukopenia were marked 2 respectively, and those who showed temporary hypothyroidism and permanent hypothyroidism were marked 1 and 2, respectively. Those who had a relapse of the disease after being cured were marked 2. The effects of two groups and total scores were compared.

RESULTSThe total score of the group treated with (131)I was 34; and the median score was 1; the total score of the group treated with ATD was 69, and the median score was 1.5; the difference between the two groups was statistically significant (P < 0.01). When these two groups were compared, the advantage of (131)I in the treatment of this disease was clear. The incidences of ophthalmopathy and improvement of ophthalmopathy of the two groups were not significantly different (P > 0.05). No significant difference was found in incidence of hypothyroidism between the two groups (P > 0.05). There was no significant worsening or new development of ophthalmopathy or hypothyroidism after (131)I and ATD treatment. The rate of relapse of hyperthyroidism among patients cured with (131)I was significantly lower than that among patients cured with ATD (P < 0.05). In the patients treated with (131)I the incidences of hyperthyroid heart disease, liver function damage, leukopenia and so on were significantly lower than those of patients treated with ATD (P < 0.05).

CONCLUSIONS(131)I therapy was superior to the ATD in treatment of the children with Graves' disease. Observations for more than 2 years after treatment with (131)I showed that there were no harmful side effects or complications. (131)I can be recognized as the safer, more convenient and effective treatment than ATD for Graves' disease in children.

Adolescent ; Antithyroid Agents ; adverse effects ; therapeutic use ; Child ; Female ; Graves Disease ; complications ; drug therapy ; radiotherapy ; Graves Ophthalmopathy ; drug therapy ; radiotherapy ; Humans ; Hyperthyroidism ; drug therapy ; radiotherapy ; Hypothyroidism ; chemically induced ; Iodine Radioisotopes ; adverse effects ; therapeutic use ; Male ; Secondary Prevention ; Severity of Illness Index ; Treatment Outcome