Carbimazole-Induced Agranulocytosis

Casebank History
1

Who you are:
FY2 in GP

Who the patient is:
32 year old lady, diagnosed with hyperthyroidism and started on Carbimazole by endocrinology. Came with complain of sore throat.

What you must do:
Please talk to him, assess him, and address his concerns.

Data gathering

  • Presenting complaints: Sore throat, Fever
  • ODIPARA
  • Other symptoms of agranulocytosis:
    • Persistent cough
    • Toothache or gum bleeding
    • Skin rash
    • Persistent mouth sores
    • Tiredness
  • Symptoms of side effect of Carbimazole:
    • Pancreatitis: Belt-like pain in upper tummy
    • Joint and muscle pain
    • Anemia
    • Liver problem (eye or skin yellowish discoloration, dark urine)
    • Bleeding and bruising easily
  • Closed questions:
    • Decreased oral intake
    • Rapid heart rate
    • Breathing difficulty
    • Neck stiffness
  • PMH
    • Hyperthyroidism history
    • On going medication? History of carbimazole intake
      • Started 2 weeks ago
  • MAFTOSA
  • ICE
  • Examination
    • Vitals (High grade fever)
    • Throat, neck and chest examination

Management

Diagnosis

  • You’ve been diagnosed with a condition called Agranulocytosis. This is when your body doesn’t have enough of a specific type of immune cells that helps fight off infections.
  • This condition can sometimes be caused by certain medications, including the one you’ve been taking for your thyroid problem.
  • Because of this condition, you might feel tired or notice things like a sore throat or fever. It’s important to recognize these symptoms because they might mean you have an infection, which could get serious if not treated. (Sepsis)
  • It's a medical emergency.

What will you do?

  • Stop the medication immediately
  • Offer broad-spectrum antibiotic without any delay (Ciprofloxacin or Ceftriaxone)
  • Immediate A&E admission to do blood tests. (FBC with differential white cell count).
  • “Don’t worry, we can manage this. We’ll do a blood test to keep an eye on your white blood cell levels. If they’re low, we might give you something to help your body make more white blood cells. We’ll make sure you get the right treatment, and we’ll monitor you closely to prevent any serious infections.”
  • Specialist referral
    • Review of Carbimazole.
    • Alternate treatment such as radiation therapy and surgery

Possibilities

  • If Count > 2 - Reassure
  • If Count 1 - 2 - Monitor FBC
  • If Count <1 - Admit & Monitor

Further Plan

  • LFT
  • Annual monitoring for
    • TFTs
    • FBCs
    • Infection markers.

Safety Net

  • If you start feeling unwell, especially if you have a fever, sore throat, or any new symptoms, it’s really important to let us know straight away. We’ll give you the right advice or treatment to keep you safe.
  • Do you understand everything so far? Please feel free to ask me any questions or let me know if there’s something you’re worried about.

Literature:

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