Thyroid storm and thionamide-induced agranulocytosis are both rare and serious medical emergencies. We report a case of a patient in which these two rare events simultaneously occurred. A 33-year-old male, maintained on Methimazole for Graves’ Disease, presented with fever, throat pain, and uncontrolled thyrotoxic symptoms. Methimazole was promptly discontinued. Thyroid storm was alternatively treated with lithium, hydrocortisone, and propranolol. Agranulocytosis was managed supportively with GCSF and empiric antibiotics. Lithium was maintained until after radioablation. When thionamides are contraindicated, lithium is a viable option for the acute management of thyroid storm and a bridge to definitive therapy.
Methimazole ; Lithium

No abstract available.
Graves Disease ; Methimazole

Methimazole is a widely used and generally well-tolerated antithyroid agent. Adverse reactions occur in 1~5% of patients taking methimazole medication, but these are most commonly transient, benign leukopenia and a skin rash. Severe cholestatic jaundice, combined with agranulocytosis, has been known as a rare complication. Herein, a case of methimazole induced cholestatic jaundice, with agranulocytosis, is reported.
Agranulocytosis* ; Exanthema ; Humans ; Jaundice, Obstructive* ; Leukopenia ; Methimazole

Insulin autoimmune syndrome, a rare cause of endogenous hyperinsulinemic hypoglycemia, is characterized by insulin autoantibody, hyperinsulinemia and fasting hypoglycemia. It is well known that drugs containing a sulfhydryl group such as methimazole or α-mercaptopropionyl glycine can induce insulin autoimmune syndrome. However, insulin autoimmune syndrome caused by anti-tuberculosis treatment is very rare. We report a case of insulin autoimmune syndrome after anti-tuberculosis treatment with a review of the relevant literature.
Glycine ; Hyperinsulinism ; Hypoglycemia ; Insulin* ; Methimazole ; Tuberculosis

Humans ; Child ; Methimazole/adverse effects* ; Graves Disease/drug therapy*

BACKGROUND: Propylthiouracil (PIV) and methimazole (MMI) were widely used for the treatment of hyperthyroidism. Hepatic injury caused by these agents is a rare but serious complication. This study is to investigate the clinical features of hepatotoxicity from antithyroid drugs. METHODS: We reviewed 17 cases of hepatic injury during treatment with antithyroid drugs in patients with hyperthyroidism. Included were 6 cases we experienced and 11 cases reported in Korean literature from 1986 to 1999. We analyzed the clinical features of hepatic injury. RESULTS: Of 17 cases of hepatic injury, 12 were PTU cases and 5 MMI cases. The mean age of PTU cases was 40 years with 6/12 patients over 40 years old and 2/5 MMI cases were over 40 years old. The dose of PTU was 300 mg/d or more in 10/12 cases (83%) and the dose of MMI was 30 mg/d in 3/5 cases (60%). The hepatic injury occurred within 3 months in 8/12 PTU cases (67%) and within 2 months in 4/5 MMI cases (80%). The duration of hepatic injury tended to be longer in MMI cases than in PTV cases (median; 80 vs 41 days, p=0.102). In PTU cases, the duration of hepatic injury was correlated with the duration of drug use before hepatic injury (p<0.05). All of 8 biopsied cases who took PTU had predominantly hepatocellular necrosis. Two biopsied cases who took MMI had cholestatic jaundice and nonspecific abnormality, respectively. Biochemical findings of all MMI cases were compatible with cholestatic jaundice. As to the treatment of hyperthyroidism after hepatic injury, 4/12 PTU cases were treated with RAI therapy, 5 with MMI and one with surgery, and treatment was unknown in two. On the other hand 3/5 MMI cases interestingly entered into spontaneous remission after hepatic injury and 2/5 had RAI therapy. Hepatic dysfunction recurred in each one whom treatment by changing to MMI or PTU was tried on. CONCLUSION: Most of hepatic injury during treatment with antithyroid drugs developed within two to three months of drug use. The hepatic injury related to PTU was mainly cytotoxic whereas that related to MMI was cholestatic. Since there is a cross-reaction between PTU and MMI in hepatotoxicity, RAI therapy or operation shoud be considered as an alternative treatment of hyperthyroidism after hepatic injury.
Adult ; Antithyroid Agents* ; Hand ; Humans ; Hyperthyroidism* ; Jaundice, Obstructive ; Methimazole ; Necrosis ; Propylthiouracil ; Remission, Spontaneous

OBJECTIVE: Since Graves' disease (GD) is resistant to antithyroid drugs (ATDs), an accurate quantitative thyroid function measurement is required for the prediction of early responses to ATD. Quantitative parameters derived from the novel technology, single-photon emission computed tomography/computed tomography (SPECT/CT), were investigated for the prediction of achievement of euthyroidism after methimazole (MMI) treatment in GD. MATERIALS AND METHODS: A total of 36 GD patients (10 males, 26 females; mean age, 45.3 ± 13.8 years) were enrolled for this study, from April 2015 to January 2016. They underwent quantitative thyroid SPECT/CT 20 minutes post-injection of (99m)Tc-pertechnetate (5 mCi). Association between the time to biochemical euthyroidism after MMI treatment and %uptake, standardized uptake value (SUV), functional thyroid mass (SUVmean × thyroid volume) from the SPECT/CT, and clinical/biochemical variables, were investigated. RESULTS: GD patients had a significantly greater %uptake (6.9 ± 6.4%) than historical control euthyroid patients (n = 20, 0.8 ± 0.5%, p < 0.001) from the same quantitative SPECT/CT protocol. Euthyroidism was achieved in 14 patients at 156 ± 62 days post-MMI treatment, but 22 patients had still not achieved euthyroidism by the last follow-up time-point (208 ± 80 days). In the univariate Cox regression analysis, the initial MMI dose (p = 0.014), %uptake (p = 0.015), and functional thyroid mass (p = 0.016) were significant predictors of euthyroidism in response to MMI treatment. However, only %uptake remained significant in a multivariate Cox regression analysis (p = 0.034). A %uptake cutoff of 5.0% dichotomized the faster responding versus the slower responding GD patients (p = 0.006). CONCLUSION: A novel parameter of thyroid %uptake from quantitative SPECT/CT is a predictive indicator of an early response to MMI in GD patients.
Antithyroid Agents ; Female ; Follow-Up Studies ; Graves Disease* ; Humans ; Male ; Methimazole* ; Thyroid Gland

Methimazole, a type of thionamide, is used to treat hyperthyroidism. Several adverse effects of thionamides have been reported. The representative minor adverse effects are arthralgia, skin rash, and gastric intolerance. Methimazole is reported to induce 1-6% of arthralgia cases. These patients begin to suffer from arthralgia from 1 month to 2 years after methimazole treatment. Here, we present a patient with acute onset methimazole-induced arthralgia and skin rash. At 2 days after starting methimazole treatment, a 57-year-old female developed arthralgia and a skin rash on her right leg, which subsequently spread to her left leg and right arm, and she stopped taking the medication. The patient was admitted to the rheumatology department of Ulsan University Hospital, where laboratory tests and a skin biopsy were performed to ascertain whether she had a rheumatic disorder. The skin biopsy revealed nonspecific inflammation. At 2 days after stopping methimazole treatment, the arthralgia and skin rashes had improved and methimazole treatment was recommenced. However, the same symptoms developed within 1 day. Therefore, methimazole treatment was again stopped and the symptoms disappeared.
Arm ; Arthralgia* ; Biopsy ; Exanthema* ; Female ; Humans ; Hyperthyroidism ; Inflammation ; Leg ; Methimazole ; Middle Aged ; Rheumatology ; Skin ; Ulsan

We report here the cases of two females with Graves' disease who developed insulin autoimmune syndrome after treatment with methimazole. The patients exhibited a sudden altered mental state after treatment with methimazole for approximately 4 weeks. Patients had hypoglycemia with serum glucose below 70 mg/dL, and laboratory findings showed both high levels of serum insulin and high titers of insulin autoantibodies. The two women had never been exposed to insulin or oral antidiabetic agents, and there was no evidence of insulinoma in imaging studies. After glucose loading, serum glucose, and total insulin levels increased abnormally. One of the patient was found to have HLA-DRB1*0406, which is known to be strongly associated with methimazole-induced insulin autoimmune syndrome. After discontinuation of methimazole, hypoglycemic events disappeared within 1 month. Insulin autoantibody titer and insulin levels decreased within 5 months and there was no further development of hypoglycemic events. We present these cases with a review of the relevant literature.
Autoantibodies ; Female ; Glucose ; Graves Disease ; HLA-DRB1 Chains ; Humans ; Hypoglycemia ; Hypoglycemic Agents ; Insulin ; Insulinoma ; Methimazole

Although rare, agranulocytosis is the most serious, potentially fatal side effect of antithyroid drug. We experienced a 13-year-old girl who developed methimazole-induced agranulocytosis at 1 month after the initiation of treatment. Her granulocyte count recovered after discontinuation of methimazole and treatment with broad spectrum-antibiotics, G-CSF, and methylprednisolone. After recovery from agranulocytosis she was treated with radioiodine ablation therapy. Early detection and proper management of antithyroid drug-induced agranulocytosis is very important.
Adolescent ; Agranulocytosis* ; Female ; Granulocyte Colony-Stimulating Factor* ; Granulocytes* ; Humans ; Methimazole ; Methylprednisolone*