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Keimyung Medical Journal 2015;34(1):64-69.
Published online June 30, 2015.
A Patient of Graves' Disease with Methimazole Induced Agranulocytosis Combined with Acute Appendicitis.
Ja Yeon Lee, Kyung Ae Lee, Tae Sun Park, Hong Sun Baek, Heung Yong Jin
Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea.
Methimazole-induced agranulocytosis is a rare but critical side effect which may cause a life-threatening state during Graves' disease treatment. In management of methimazole-induced agranulocytosis, the most important thing is withdrawal of ATD (anti-thyroid drug) and empirical broad spectrum antibiotics can be used. Also, G-CSF or GM-CSF is generally recommended as it could be helpful in restoration of neutropenia. Pathophysiology of appendicitis is obstruction of the lumen of the appendix caused by infection or hyperplasia of submucosal follicles. Recently, management of appendicitis has been reported to be successful with conservative antibiotics administration without appendectomy. A 27-year-old man visited our hospital experiencing febrile sensation, painful throat, and abdominal pain. The patient had been diagnosed with Graves' disease 1 month previously and had taken methimazole 10 mg daily (tapered dose from initial 30 mg daily). Agranulocytosis was confirmed with neutrophils count and peripheral blood smear, and the finding of ultrasonography and abdominal CT scan were compatible with acute appendicitis. We report a rare case of methimzole-induced agranulocytosis combined with acute appendicitis in the course of Graves' disease treatment. In this case, withdrawal of ATD (anti-thyroid drug) caused thyroid storm and appendectomy was not performed due to operative risk. Thyroid storm was treated with radioiodine ablation, and appendicitis was treated with antibiotics without appendectomy. With the use of G-CSF and conservative management, improvement of not only the clinical manifestation but also agranulocytosis was seen.
Key Words: Acute appendicitis, Agranulocytosis, Graves' disease, Methimazole
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