ESPE Abstracts (2019) 92 P3-259

Graves' Disease in a 3 Year-Old Patient with Agranulocytosis due to Methimazole

Emine Demet Akbas, Yilmaz Kor


Adana City Training and Research Hospital, Adana, Turkey


Introduction: Graves' disease is the most common cause of hyperthyroidism in children with autoimmune thyroid disease. Clinically, goiter, tachycardia, restlessness, craniosinostosis, hyperactivity, growth retardation, diarrhea may occur.Graves' disease is rare under 4 years of age. Treatment options include antithyroid therapy, surgery, and radioiodine therapy. The most commonly used antithyroid therapy is methimazole and has serious side effects such as hepatitis, neutropenia and agranulocytosis.

Case:

The patient was 3 years and 2 months old girl, was referred to the external center for restlessness.She had no additional complaints . She was born term 2800 gr. In her past medical history, there was no thyroid disease, but she was being followed up by pediatric neurology and genetics because of microcephaly, growth retardation. In her physical examination; weigth:10,2 kg (-2,81 SD), heigth:86,8 cm (-2,48 SD), thyroid was nonpalpable, puberty was Tanner stage 1, heart rate 125/ min, BP: 100/60 mm/Hg. Laboratory results:fT3:7,78 pg/ml, fT4: 2,79 ng/dl, TSH: <0,005 uIU/ml, anti Tg:0,Anti TPO: 33,9 IU/ mL, Thyrobulin:42,85 TSH receptor antibody:8,2 U/L (N=0-14 ), urine iodine:145,4 ug/L.

In her thyroid ultrasound, it was heterogeneous.In thyroid scintigraphy, thyroid gland is in normal location, there is a slight increase in the size of the gland.

1 mg/kg propranolol and 0.5 mg/kg/day metimazole treatment were started. At 4th month of treatment, she was atmitted to emergency polyclinic with fever complaint. Her physical examination was normal but in CBC, WBC 1700 uL, ANC 800 uL. She was evaluated by pediatric hematology. Her viral markers were negative. methimazole was discontinued because of its side effect.On the 20th day of her follow-up, her hemogram returned to normal, she was hyperthyroid again(sT3: 4,7 pg/ml, sT4: 1,46 ng/dl, TSH: 0,051 uIU/ml, thyroglobulin:26 ng/ml TSH receptor ab: 23,73 U/L) and methimazole treatment was started. In the last follow-up visit, the patient's thyroid function tests, euthyroid and hemogram were normal.

Conclusion: Graves' disease is the most common cause of hyperthyroidism in childhood and it is rarely seen in children under 4 years of age. Antithyroid therapy, which is the first treatment option, has a serious complication such as agranulocytosis. It is usually dose dependent and can be seen within the first 6 months after the treatment and it is most common in the first 3 months. Patients should be closely followed because of the risk of agranulocytosis, if necessary, a different treatment option such as thyroidectomy or radioiodine therapy should be tried.

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