Skip to main content Skip to main navigation menu Skip to site footer

Management of thyroid crisis in a patient with febrile neutropenia

  • Wira Gotera ,
  • Stephanie Sugiharto ,
  • Ida Bagus Aditya Nugraha ,


Abstract

Introduction: Thyroid storm is a life-threatening complication of acute hyperthyroidism. The diagnosis of thyroid storm can only be based on its clinical manifestations, which include decreased consciousness, high fever, heart failure, diarrhea and jaundice. Antithyroid drug therapy (ATD) is one option for treating hyperthyroidism, along with surgery and radioactive iodine. ATD is thought to cause neutropenia through the agranulocytosis pathway. The most common symptoms are fever and sore throat accompanied by symptoms of a thyroid crisis. There is no specific method for predicting the appearance of febrile neutropenia caused by ATD. Routine complete blood counts in patients taking ATD should be performed. The diagnosis of febrile neutropenia due to ATD needs to be done immediately so that timely intervention can be carried out and reduce mortality.

Case Presentation: a 25 years old female with thyroid crisis and febrile neutropenia. Clinical findings in the patient include fever, decreased consciousness, palpitation, excessive sweat, diarrhea, nausea and vomiting, weight loss, and the laboratory findings of leukopenia and neutropenia of (leucocyte 1.03x103/uL, neutrophil 1.90x103/ul). Ultrasonography examination of the thyroid reveals a thyroiditis image with multiple solid nodules. Blood smear examination reveals leukopenia with differential count examination of blood showed neutropenia, moderate lymphocytosis, erythrocyte hypochromic micrositer, poikilocytosis ovalocyte, teardrop cell, fragmentosist and target cell. Polychromasia and normoblast cells are not found.

Conclusion: Thyroid crisis refers to the clinical findings and thyroid hormone test results. There is no specific method to predict the appearance of febrile neutropenia caused by the antithyroid drug. Frequent blood tests must be done in patients who consume antithyroid drugs.

Keywords: thyroid crisis febrile neutropenia antithyroid drug therapy

References

  1. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016 Oct;26(10):1343-1421.
  2. Pokhrel B, Aiman W, Bhusal K. Thyroid Storm. [Updated 2022 Jun 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448095/
  3. Vicente N, Cardoso L, Barros L, Carrilho F. Antithyroid Drug-Induced Agranulocytosis: State of the Art on Diagnosis and Management. Drugs R D. 2017 Mar;17(1):91-6.
  4. Ming-Tsung Sun, Chen-Hao Tsai, Kuang-Chung Shih. Antithyroid Drug-induced Agranulocytosis.Journal of the Chinese Medical Association.Volume 72, Issue 8,2009,Pages 433-441.ISSN 1726-490.
  5. Andres E, Zimmer J, Affenberger S, Federici L, Alt M, Maloisel. F. Idiosyncratic drug-induced agranulocytosis: update of an old disorder. Eur J Intern Med. 2006;17(8):529–35.
  6. Solomou, Elena & Salamaliki, Christina & Lagadinou, Maria. (2021). How to Make the Right Diagnosis in Neutropenia. Clinical Hematology International. 3. 10.2991/chi.k.210216.001..
  7. Idrose AM. Acute and emergency care for thyrotoxicosis and thyroid storm. Acute Med Surg. 2015 May 12;2(3):147-57.
  8. Armstrong M, Asuka E, Fingeret A. Physiology, Thyroid Function. [Updated 2022 Mar 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022Jan.Availablefrom:https://www.ncbi.nlm.nih.gov/books/NBK537039/.
  9. Mughal BB, Fini JB, Demeneix BA. Thyroid-disrupting chemicals and brain development: an update. Endocr Connect. 2018 Apr;7(4):160-R86.
  10. Karapanou O, Tzanela M, Vlassopoulou B, Kanaka-Gantenbein C. Differentiated thyroid cancer in childhood: a literature update. Hormones (Athens). 2017 Oct;16(4):381-387.
  11. The long-term outcome of treatment for Graves' hyperthyroidism. Sjölin G, Holmberg M, Törring O, et al. Thyroid. 2019;29:1545–57.
  12. Siddamreddy S, Dandu VH. Thyrotoxic Periodic Paralysis. [Updated 2022 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560670/
  13. Solomou EE, Salamaliki C, Lagadinou M. How to Make the Right Diagnosis in Neutropenia. Clin Hematol Int. 2021;3(2):41-46. Published 2021 Feb 26. doi:10.2991/chi.k.210216.001
  14. Andrès E, Lorenzo Villalba N, Mourot-Cottet R, Maloisel F, Tebacher M, Gottenberg JE, Goichot B, Herbrecht R, Zulfiqar AA. Severe Neutropenia and Agranulocytosis Related to Antithyroid Drugs: A Study of 30 Cases Managed in A Single Reference Center. Medicines (Basel). 2020 Mar 19;7(3):15.
  15. Tan S, Chen L, Jin L, Fu X. The efficiency and safety of methimazole and propylthiouracil in hyperthyroidism: A meta-analysis of randomized controlled trials.Medicine(Baltimore).2021;100(30):e26707.doi:10.1097/MD.0000000000026707
  16. Yang J, Zhong J, Xiao XH, Zhou LZ, Chen YJ, Liu JH, et al. The relationship between bone marrow characteristics and the clinical prognosis of antithyroid drug-induced agranulocytosis. Endocr J 2013; 60: 185-9.
  17. Kim H, Lee J, Ha J. A case of antithyroid drug-induced agranulocytosis from a second antithyroid drugs (ATD) administration in a relapsed Graves' disease patient who was tolerant to the first ATD treatment. Clin Case Rep. 2018 Jul 10;6(9):1701-3.
  18. Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010;1(3):139-145. doi:10.1177/2042018810382481.
  19. Watanabe N, Narimatsu H, Noh JY, Yamaguchi T, Kobayashi K, Kami M, et al. Antithyroid drug induced hematopoietic damage: a retrospective cohort study of agranulocytosis and pancytopenia involving 50.385 patients with Graves’ disease. J. Clin Endocrinol Metab. 2012;97(1):49-53.
  20. Nakamura H, Miyauchi A, Miyawaki N, Imagawa J. Analysis of 754 cases of antithyroid drug-induced agranulocytosis over 30 years in Japan. J Clin Endocrinol Metab. 2013;98(12):4776–83.

How to Cite

Gotera, W., Sugiharto, S., & Nugraha, I. B. A. (2023). Management of thyroid crisis in a patient with febrile neutropenia. Intisari Sains Medis, 14(1), 131–137. https://doi.org/10.15562/ism.v14i1.1577
ACM ACS APA ABNT Chicago Harvard IEEE MLA Turabian Vancouver
Download Citation
Endnote/Zotero/Mendeley (RIS) BibTeX

HTML
0

Total
0

Share

Search Panel

Wira Gotera
Google Scholar
Pubmed
ISM Journal

Stephanie Sugiharto
Google Scholar
Pubmed
ISM Journal

Ida Bagus Aditya Nugraha
Google Scholar
Pubmed
ISM Journal