A Challenge

Sometimes you're just stuck between a rock and a hard place.

I saw my 2nd most challenging hyperthyroid case while oncall last week. The patient was a man in his 30s with Graves' disease.

Prior to his admission, he had been on a course of antithyroid. Unfortunately, he developed a rare but severe case of agranulocytosis, to the point of becoming septic and had needed Neupogen to bring things up. He then developed a stomach ulcer that perforated, requiring multiple emergent surgeries and prolonged TPN.

By the time I was involved in his care, he was fast becoming hyperthyroid again. Steroids did not help, and out of the lack of anything better, we bit the bullet and treated him with Potassium Iodide, hoping to take advantage of the Wolf-Chaikoff effect. Except with no good oral route, we tried something that has been published in case reports to work: rectal SSKI.

When the pharmacist got the order, we got a prompt call: "You want to do WHAT??"

Well, it worked, and dropped his FT4 like a rock. Problem was, iodine works only temporarily, and prolonged exposure eventually leads to increased thyroxine synthesis. And being a pretty sick guy, the surgeons were not too keen on taking him for surgery to remove his thyroid, while radioablation would take months to work. In the meantime his Ft4 crept up from 0.5 to 1.4 to 5.5. He became more and more tachycardic despite beta blockers. I was concerned that if I did nothing, he would go into a thyroid storm.

I had to bite the bullet. Despite his severe agranulocytosis in the past (his white cell count had now more than normalized) I resumed his medications, this time picking Propylthiouracil over the Methimazole that was previously implicated. I told my resident to watch over his labs like a hawk.

I signed off his care to a colleague a few days ago. I pray that in this difficult situation, we made the right choice.