UNUSUAL SCINTIGRAPHIC FINDING IN A PATIENT WITH AMIDOARONE-INDUCED THYROTOXICOSIS: A CASE REPORT

  • Anamarija Jankulovska Institute of Pathophysiology and Nuclear Medicine "Acad Isac S. Tadzer", Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, R. North Macedonia
  • Daniela Miladinova Institute of Pathophysiology and Nuclear Medicine "Acad Isac S. Tadzer", Faculty of Medicine, Ss. Cyril and Methodius University in in Skopje, R. North Macedonia

Abstract

Amiodarone, an antiarrhythmic drug with 37% iodine of its weight, is often used for treatment of severe cardiac arrhythmias. Enormous iodine content and structural similarity to thyroxine leads to thyroid dysfunction in 14-18% of patients. A 64-year-old man presented at our department with signs of thyrotoxicosis for further work up. He reported taking amiodarone for treatment of atrial fibrillation for two years. The patient denied any thyroid dysfunctions in the past. Full thyroid examination revealed elevated FT4 and suppressed TSH, with undetectable level of thyroid antibodies, increased iodine urinary concentration and normal thyroid ultrasound features. Although the above mentioned was indicative for amiodarone-induced thyrotoxicosis (AIT) type 2, 99mTc-pertechnetate scan showed normal thyroid uptake, highly unusual for iodine contamination and destructive thyroiditis. We presumed that this was a mixed form of AIT. Amiodarone administration was stopped and the patient was put on antithyroid drug therapy with thiamazole. During the follow up period he became clinically and biochemically euthyroid and thiamazole was discontinued. Thyroid screening should be performed in all patients undergoing amiodarone treatment. The presented case highlights the challenge of differentiation and management of a form of AIT with mixed features of both types.


 Keywords: iodine excess, amiodarone induced thyrotoxicosis, mixed form

References

1. Epstein AE, Olshansky B, Naccarelli GV, Kennedy JI Jr, Murphy EJ, Goldschlager N. Practical Management Guide for Clinicians Who Treat Patients with Amiodarone. Am J Med. 2016 May;129(5):468-75. Doi: 10.1016/j.amjmed.2015.08.039.
2. Trohman RG, Sharma PS, McAninch EA, Bianco AC. Amiodarone and thyroid physiology, pathophysiology, diagnosis and management. Trends Cardiovasc Med. 2019 Jul;29(5):285-295. Doi: 10.1016/j.tcm.2018.09.005.
3. Cohen-Lehman J., Dahl P., Danzi S., Klein I. Effects of amiodarone therapy on thyroid function. Nature reviews. Endocrinology. 2009 Nov; 6 (1):34-41. Doi: 10.1038/nrendo.2009.225.
4. Bogazzi F, Bartalena L, Martino E. Approach to the Patient with Amiodarone-Induced Thyrotoxicosis.The Journal of Clinical Endocrinology and Metabolism, June 2010; 95 (6):2529–2535. Doi: 10.1210/jc.2010-0180.
5. Palermo-Garófalo C, Martínez JH, Silva F, González E, Torres O, Figueroa J, González J, de Lourdes MM. The cardiology and endocrinology connection between amiodarone and thyrotoxicosis: case report and review of the literature. Bol Asoc Med P R. 2013;105(2):47-53.
6. Bartalena L, Bogazzi F, Chiovato L, Hubalewska-Dydejczyk A, Links TP, Vanderpump M. 2018 European Thyroid Association (ETA) Guidelines for the Management of Amiodarone-Associated Thyroid Dysfunction. Eur Thyroid J. 2018 Mar;7(2):55-66.Doi: 10.1159/000486957.
7. Tsang W, Houlden RL. Amiodarone-induced thyrotoxicosis: a review. Can J Cardiol. 2009 Jul;25(7):421-4. Doi: 10.1016/s0828-282x(09)70512-4.
8. Institute of Medicine (US) Panel on Micronutrients. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington (DC): National Academies Press (US); 2001. PMID: 25057538.
9. Elnaggar MN, Jbeili K, Nik-Hussin N, Kozhippally M, Pappachan JM. Amiodarone-Induced Thyroid Dysfunction: A Clinical Update. Exp Clin Endocrinol Diabetes. 2018 Jun;126(6):333-341. doi: 10.1055/a-0577-7574.
10. Leung AM, Braverman LE. Iodine-induced thyroid dysfunction. Curr Opin Endocrinol Diabetes Obes. 2012 Oct;19(5):414-9. doi: 10.1097/MED.0b013e3283565bb2
11. Lee SY, Rhee CM, Leung AM, Braverman LE, Brent GA, Pearce EN. A review: Radiographic iodinated contrast media-induced thyroid dysfunction. J Clin Endocrinol Metab. 2015 Feb;100(2):376-83. doi: 10.1210/jc.2014-3292.
12. Thomson CD, Campbell JM, Miller J, Skeaff SA. Minimal impact of excess iodate intake on thyroid hormones and selenium status in older New Zealanders. Eur J Endocrinol. 2011 Nov;165(5):745-52. doi: 10.1530/EJE-11-0575.
13. Li D, Cai W, Gu R, Zhang Y, Zhang H, Tang K, Xu P, Katirai F, Shi W, Wang L, Huang T, Huang B. Th17 cell plays a role in the pathogenesis of Hashimoto's thyroiditis in patients. Clin Immunol. 2013 Dec;149(3):411-20. doi:10.1016/j.clim.2013.10.001.
14. Singh BN. Amiodarone as paradigm for developing new drugs for atrial fibrillation. J Cardiovasc Pharmacol. 2008 Oct;52(4):300-5. Doi: 10.1097/FJC.0b013e31818914b6.
15. Narayana SK, Woods DR, Boos CJ. Management of amiodarone-related thyroid problems. Ther Adv Endocrinol Metab. 2011 Jun;2(3):115-26. Doi: 10.1177/2042018811398516.
16. Tsadok MA, Jackevicius CA, Rahme E, Essebag V, Eisenberg MJ, Humphries KH, Tu JV, Behlouli H, Joo J, Pilote L. Amiodarone-induced thyroid dysfunction: brand-name versus generic formulations. CMAJ. 2011 Sep 6;183(12):E817-23. Doi: 10.1503/cmaj.101800.
17. McDermott MT. Hyperthyroidism. Ann Intern Med. 2020 Apr 7;172(7):ITC49-ITC64. doi: 10.7326/AITC202004070.
18. Foppiani L, Cascio C, Lo Pinto G. Iodine-induced hyperthyroidism as combination of different etiologies: an overlooked entity in the elderly. Aging Clin Exp Res. 2016 Oct;28(5):1023-7. doi: 10.1007/s40520-015-0483-4.
19. Theodoraki A, Vanderpump MPJ. Thyrotoxicosis associated with the use of amiodarone: the utility of ultrasound in patient management. Clin Endocrinol (Oxf). 2016 Feb;84(2):172-176. Doi: 10.1111/cen.12988.
20. Hashimoto K, Ota M, Irie T, Takata D, Nakajima T, Kaneko Y, Tanaka Y, Matsumoto S, Nakajima Y, Kurabayashi M, Oyama T, Takeyoshi I, Mori M, Yamada M. A Case of Type 2 Amiodarone-Induced Thyrotoxicosis That Underwent Total Thyroidectomy under High-Dose Steroid Administration. Case Rep Endocrinol. 2015;2015:416145. Doi: 10.1155/2015/416145.
21. Calissendorff J, Falhammar H. Lugol's solution and other iodide preparations: perspectives and research directions in Graves' disease. Endocrine. 2017;58(3):467-473. Doi:10.1007/s12020-017-1461-8
22. Mateo Gavira I, Vilchez López F, Larrán Escandón L, Roldán Caballero P, Aguilar Diosdado M. Manejo de la tirotoxicosis grave por amiodarona cuando fracasa el tratamiento médico convencional [Management of severe amiodarone-induced thyrotoxicosis after failure of standard medical treatment]. Endocrinol Nutr. 2013 Dec;60(10):43-5. Spanish. Doi: 10.1016/j.endonu.2013.01.003.
23. Kotwal, A., Touchan, B., Seetharaman, K., Haas, R., Lithgow, M., & Malkani, S. (2015). Mixed Amiodarone-Induced Thyrotoxicosis Refractory to Medical Therapy and Plasmapheresis. Journal Of Endocrinology And Metabolism, June 2015; 5(3), 220-223. Doi: 10.14740/jem278w
24. De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016 Aug 27;388(10047):906-918. doi: 10.1016/S0140-6736(16)00278-6.
25. Czarnywojtek A, Płazińska MT, Zgorzalewicz-Stachowiak M, Woliński K, Stangierski A, Miechowicz I, Waligórska-Stachura J, Gut P, Królicki L, Zioncheck M, Ruchała M. Dysfunction of the thyroid gland during amiodarone therapy: a study of 297 cases. Ther Clin Risk Manag. 2016 Apr 4;12:505-13. doi: 10.2147/TCRM.S96606.
26. Isaacs M, Costin M, Bova R, Barrett HL, Heffernan D, Samaras K, Greenfield JR. Management of Amiodarone-Induced Thyrotoxicosis at a Cardiac Transplantation Centre. Front Endocrinol (Lausanne). 2018 Aug 22;9:482. Doi: 10.3389/fendo.2018.00482.
27. Sudheer Ahamed P, Mathew A. A Case of Amiodarone-Induced Thyrotoxicosis: A diagnostic and therapeutic dilemma. Sultan Qaboos Univ Med J. 2009 Dec;9(3):319-23.
28. Khan A, Puttanna A, Raskauskiene D. Amiodarone-induced thyrotoxicosis: type 1 or type 2? BMJ Case Rep. 2014 Oct 27;2014:bcr2014204485. Doi: 10.1136/bcr-2014-204485. PMID: 25349184; PMCID: PMC4212191.
29. Danzi S, Klein I. Amiodarone-induced thyroid dysfunction. J Intensive Care Med. 2015 May;30(4):179-85. Doi: 10.1177/0885066613503278.
Published
2021-12-25
How to Cite
JANKULOVSKA, Anamarija; MILADINOVA, Daniela. UNUSUAL SCINTIGRAPHIC FINDING IN A PATIENT WITH AMIDOARONE-INDUCED THYROTOXICOSIS: A CASE REPORT. Journal of Morphological Sciences, [S.l.], v. 4, n. 3, p. 14-20, dec. 2021. ISSN 2545-4706. Available at: <https://jms.mk/jms/article/view/260>. Date accessed: 20 jan. 2022.
Section
Articles