ESPE2015 Poster Category 3 Thyroid (64 abstracts)
Angioneurotic Oedema with Antithyroid Drugs in Thyroid Storm: What is the Best Therapeutic Option
Pelin Bilir a , Mehmet Isakoca a , Aydan Ikinciogullari b , Figen Dogu b , Sule Haskaloglu b , Demet Corapcioglu c , Rifat Emral c , Suat Fitoz d , Adalet Elcin Yildiz d , Metin Kir e , Gulnur Göllü Bahadir f , Bilge Türedi f & Hüseyin Dindar f
aDepartment of Pediatric Endocrinology, Medical Faculty, Ankara University, Ankara University Ankara, Turkey; bDepartment of Pediatric Immunology and Allergy, Medical Faculty, Ankara University, Ankara, Turkey; cDepartment of Endocrinology and Metabolism, Medical Faculty, Ankara University, Ankara, Turkey; dDepartment of Radiology, Medical Faculty, Ankara University, Ankara, Turkey; eDepartment of Nuclear Medicine, Medical Faculty, Ankara University, Ankara, Turkey; fDepartment of Pediatric Surgery, Medical Faculty, Ankara University, Ankara, Turkey
Background: Graves disease is the most common cause of hyperthyroidism in children. The frequency of the disease increases with age, peaking during adolescence.Thyroid storm is a rare but critical, ilness that can lead to multiorgan failure and carries a high death rate. Antithyroid drugs are usually recommended as the initial treatment and are generally well tolerated. Although current treatment options include radioactive iodine, but long term complications of thyroid irradiation is not well known. Near total or total thyroidectomy is an acceptable form of therapy too. Reactions to antithyroid drug medication makes the decision harder for choosing the suitable therapeutic option.
Case: A 10 years old girl administrated to our outpatient clinic with palpitation, tremor, anxiety, sleepless, weight loss and fatigue. She was administered to another center with thyroid storm and diagnosed as Graves disease. The antithyroid drug therapy (methimazole and propranalol) was initiated to patient but she had angioneurotic edema. Following either propranalol or methimazole administration alone resulted with angioneurotic edema. In this situation the patient was reffered to our clinic for radioactive iodine ablation therapy. Physical examination and laboratory findings were given at Table 1. Under this circumstances thyroid ablation with 131I seems to be a good solution but her iodine turnover was very high (4th h: 62.4%; 24th h 54.6%) and so the response will be poor and needs to be administered with higher recurent doses. Plasmapheresis could be another option in preparation for total thyroidectomy but it was risky.High dose oral glucucorticoid and antihistaminic therapy combined with propranolol was administered before surgery. Her thyroid hormone levels were decreased %70 in a week and total thyroidectomy was performed without any complication Postoperation period LT4 therapy was initiated.
| Laboratory findings | Our patient initial values | After high dose oral glucucorticoid and antihistaminic therapy values | Postoperative values |
| Physical examination | Height: 137.3 cm (HSDS:−1.3) Weight: 29.5 (BMI: 15.7) Heart rate: 125/min Goiter and tremor | Height: 139 cm (HSDS:−1,2) Weight: 31 (BMI: 16.06) Heart rate: 75/min | |
| fT3 | 36.31 pmol/l (3.8–6 pmol/l) | 6,02 pmol/L | 3,8 pmol/L |
| FT4 | 71.5 pmol/l (7–16 pmol/l) | 21.96 pmol/l | 15.36 pmol/l |
| TSH | 0.02 mcIU/ml (0.34–5.6 mcIU/ml) | ||
| TRAb | 405 U/l (0–9 U/l) | ||
| Thyroglobulin Ab | 311.1 IU/ml (negative) | ||
| TPO Ab | 221.4 IU/ml (negative) | ||
| Hemogram | Hemoglobin:14,5 g/dl Leucocyte: 7400/mm3 Platelet: 319 000/mm3 | Hemoglobin: 14.6 g/dl Leucocyte: 23 200/mm3 Platelet: 277 000/mm3 | |
| Liver functions | AST: 18 U/l (<41) ALT: 17 U/l (<34) | ||
| Thyroid Color Doppler Ultrasonography | Thyroid volume: 14.1 ml (>+2 S.D.) Parenchyma in heterogeneous appearance, increased thyroid blood flow | Thyroid volume: 12.36 ml (>+2 S.D.) Parenchyma in heterogeneous appearance | |
| Thyroid Scintigraphy | Thyroid uptake above the normal limit (4th h: 62.4%; 24th h 54.6%) |
Conclusion: In conclusion inorder to underline allergical reactions of antithyroid therapy, we wanted to remined oral steroid therapy benefits combined with surgery.
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