A Doc in Trouble with his own thyroid...

[gunmetal83]

Hi Dr. Lupo
i am an ER Physician myself, male, aged 26, with no family hx of thyroid disease. about 2 months back i suddenly started losing weight and i lost about 12kgs in 2-3 weeks. my seniors advised me all labs and as expected i was found to be hyperthyroid. without further investigations they started me on carbimzole 35mg as BD dose and inderal 20mg BD dose. an ultrasound about 10 days during treatment showed very minute hypo-echoic regions in the thyroiid with no big nodules annd only slight increased vascularity with normal gross size.

in about 20 days into my treatment i got a cough and sore throat and as advised i did my cbc lfts and tfts.cbc was normal with mild neutrophil count elevation (sore throat). my t3 t4 came back within normal ranges but my tsh still remained 0.0 with my TPO anitbodies 1300. then after one day of reassurance from my endocrinologist i started having a severe rash, migratory urticarial in nature, itchy, involving the small joints of the hands and the neck with elements of conjunctivitis. i was admitted, stopped all treatment and given IV steroids and chlorpheniramine which resolved the rash in about 3 days. now i havent started the carbimazole back because the endocrinologist wont take more chances with the rash, he doesnt like propylthouracil because it has a higher incidence of rashes and sensitivity too (although in books about half as much as carbimazole).
now i am stuck on a cross roads with these possibilities:

1. i try carbimazole low dose with chlorpheniramine.
2. i start PTU (propylthiouracil) without taking an iodine scan
3. i wait for a few weeks (i dont knw the suitable time?)for the carbimazole to wean off and get an iodine scan to confirm a diagnosis. and then proceede accordingly.
4. i perform radio iodine ablation of the thyroid ( worried: cz i am not  married Yet and i crave for children)
5. i go for total or subtotal thyroidectomy and take thyroxin for life.

i need ur expert advice please!
Dr Saad

[Mark Lupo, M.D.]

This is most likely Graves disease - an I-123 scan would confirm this, also TSI and TBII would be an easier way to support this diagnosis.

The TSH often remains low for several months - so following T4 and T3 resoponse to anti-thyroid therapy is the key -- in your case, with normal levels, would consider re-challenging w/ carbimazole at lower dose (we use methimazole in the states and 10-15mg/day dosing is usually adequate and has less side effects).  PTU is less favorable due to increase incidence of hepatoxicity, and bid-tid dosing.

Surgery or I-131 would be definitive treatment, but make  you hypothyroid lifelong and dependent on levothyroxine.  Many Graves pts need this, but I usually try anti-thyroid meds first to see if we can achieve a remission.

[gunmetal83]

i Plan to wait for a while, get the scan done and tsi and confirm it befor i give carbimazole another try on low dose as u said. if it works, nothing like it. but if God wouldnt mind a big scar on my neck; so shouldnt i, i think :)
thanks for the help though.
m obliged

[gunmetal83]

sir i am still awaiting a reponse...