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This patient should receive routine complete blood counts to screen for agranulocytosis
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This patient should receive routine complete blood counts with a differential to screen for agranulocytosis
This patient should be cautioned to stay out of the sun because of increased photosensitivity
This patient may continue this medication when pregnant
This patient should stop medication and receive a complete blood count at any sign of infection
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The most feared side effect of propylthiouracil and methimazole (both antithyroid medications) is agranulocytosis, immune destruction of granulocytes. If a patient taking either of these drugs reports a fever or any sign of an infection the medications should be stopped and a white blood count should be measured immediately. This is more cost effective than routinely measuring white blood cell counts in patients on these antithyroid medications. Graves' disease is the most common cause of hyperthyroidism. An autoimmune process causes production of anti-TSH receptor antibodies. Patients are most commonly female and present in times of stress such as childbirth and infection. Symptoms include the classic features of hyperthyroidism such as heat intolerance, weight loss, diarrhea, tachycardia, and sweating. Treatment centers on beta blockers, Iodine-131 ablation, and thionamides such as PTU and methimazole. Each of these medications is associated with agranulcytosis. Other potential side effects of these drugs are aplastic anemia and a skin rash. Furthermore, methimazole is teratogenic. Reid et al. discuss the diagnosis and treatment of hyperthyroidism. The most common cause of hyperthyroidism is Graves' disease. Other common causes include thyroiditis, toxic multinodular goiter, toxic adenomas, and side effects of certain medications. The diagnostic workup begins with a thyroid-stimulating hormone level test. Mutharasan et al. describe delayed antithyroid drug-induced agranulocytosis. Agranulocytosis may present long after the initiation of drug therapy. Thus, it is important to remain aware of signs of agranulocytosis throughout the course of treatment, even after years. Illustration A depicts the classic findings of Grave's ophthalmopathy and thickening around the extraocular muscles. Incorrect Answers: Answers 1 and 2: Routine screening by CBC or CBC with differential in the absence of symptoms is not cost effective and provides no greater benefit. Answer 3: Photosensitivity is a side effect common to many drugs that regulate the endocrine system, such as demeclocycline, but is not a feature of antithyroid medications. Answer 4: Methimazole is a known teratogen and should not be taken during pregnancy.
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