Keimyung Med J.  2015 Jun;34(1):64-69. 10.0000/kmj.2015.34.1.64.

A Patient of Graves' Disease with Methimazole Induced Agranulocytosis Combined with Acute Appendicitis

• Lee JY
• Lee KA
• Park TS
• Baek HS
• Jin HY

• KMID: 2093092
• DOI: http://doi.org/10.0000/kmj.2015.34.1.64

Abstract

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.

Keyword

Acute appendicitis; Agranulocytosis; Graves' disease; Methimazole

MeSH Terms

Abdominal Pain
Adult
Agranulocytosis*
Anti-Bacterial Agents
Appendectomy
Appendicitis*
Appendix
Granulocyte Colony-Stimulating Factor
Granulocyte-Macrophage Colony-Stimulating Factor
Graves Disease*
Humans
Hyperplasia
Methimazole*
Neutropenia
Neutrophils
Pharynx
Sensation
Thyroid Crisis
Tomography, X-Ray Computed
Ultrasonography
Anti-Bacterial Agents
Granulocyte Colony-Stimulating Factor
Granulocyte-Macrophage Colony-Stimulating Factor
Methimazole