28-03-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
PPM 3 - The patient started having symptoms around the first month of her first pregnancy (five years
ago) and was prescribed Propylthiouracil 50mg almost immediately by a local physician.
She followed up with this physician only once since then (sometime in the duration of the first
pregnancy itself) for a dose change and has continued to take the same dose for the last five years until
1 month ago, when she first came here to get a dental examination done, but was referred to General
Medicine due to the goitre.
PPM 1 - Yes if you see the first prescription image in her case report dated January 2021 you will find
mentioned as post partum.
Let's also add this initial history narrative text in the case report beginning @Sailaja
Let's elaborate her events sequences
What were her thyroid function tests like since 2021?
PPM 3 - Sir, her earliest thyroid profile shows
T3: 3.71
T4: 15.7
TSH: 0.01
Her last test done in 2023 with the other practitioner (when she was pregnant with her second child) shows
T3: 2.00
T4: 14.35
TSH: 0.05
And her tests done here one month ago show:
T3: 1.63
T4: 25.81
TSH: 0.001.
PPM 1 - She never had normalisation of her thyroid profile and yet remained asymptomatic?
Can we have an event timeline of her symptoms as to when did she actually experience her symptoms
of thyrotoxicosis and when was she symptoms free?
[28-03-2025 13:02] PPM 1: Add clinical images @~PPM3 @~PPM4
[28-03-2025 13.07] PPM 1: Once we have started all her data including all her requirements here(Varun had some interesting questions, please add him here @PPM4. We can add the patient too to share her daily input output.
[28-03-2025 13.08] PPM 1: @CR may need to youtube all the video data and share the links in the case report.
[28-03-2025 13.09] PPM 1: Please share your questions here @PPM5
[28-03-2025 13:09] PPM 5: Kk sir
[28-03-2025 13:10] PPM 1: This has come out well. Can edit to shorten the frame @CR such that her chin and earrings are not visible to remove as much potential identifiers.
[28-03-2025 13:11] PPM 3: I'll do it and send sir
[28-03-2025 13:11] PPM 1: The above documents will need to be deleted after cropping identifiers and resharing them here
[28-03-2025 13:14] PPM 5: Sir she asked for while taking treatment which food should be avoided
[28-03-2025 13:15] PPM 1: @~PPM4 will search for this answer
After @Meta AI tells us about if there's any particular foods to avoid in Graves disease
Graves' disease is an autoimmune disorder that affects the thyroid gland, causing hyperthyroidism. While there isn't a specific "Graves' disease diet," some foods may exacerbate symptoms or interfere with treatment. Here are some foods to limit or avoid:
# Iodine-rich foods
1. Kelp and other seaweeds: High in iodine, which can worsen hyperthyroidism.
2. Iodized salt: Limit excessive consumption, as it may exacerbate thyroid issues.
# Foods that may interfere with medication
1. Soy products: May interfere with thyroid medication absorption.
. Fiber-rich foods: While fiber is essential, high amounts may reduce medication absorption. Take medication at least 30 minutes before or after eating fiber-rich foods.
# Foods that may trigger inflammation
1. Gluten: Some people with Graves' disease may have a gluten intolerance, which can trigger inflammation.
2. Processed foods: Limit foods high in sugar, salt, and unhealthy fats, as they can promote inflammation.
# Other considerations
1. Caffeine: May worsen anxiety, palpitations, and insomnia associated with hyperthyroidism. Limit or avoid caffeine.
2. Alcohol: May interact with thyroid medication and worsen symptoms.
# Focus on a balanced diet
While avoiding certain foods, focus on a nutrient-rich diet with:
- Fresh fruits and vegetables
- Whole grains
- Lean proteins
- Healthy fats
- Calcium-rich foods (to support bone health)
Remember, everyone's nutritional needs and health goals are different. Consult with your healthcare provider or a registered dietitian to develop a personalized diet plan that suits your needs with Graves' disease.
[28-03-2025 13:16] PPM 5: And there is any dietary associated treatment.
[28-03-2025 13:16] PPM 1: @Meta AI please share any randomized controlled trial evidence to support your dietary recommendation for Graves disease along with valid searchable references
[28-03-2025 13:16] Meta AI: While there isn't a specific "Graves' disease diet," some foods may
exacerbate symptoms or interfere with treatment. Here are some evidence-based dietary
recommendations:
- Iodine-rich foods: Limit or avoid foods high in iodine, such as kelp and seaweed, as they can worsen hyperthyroidism.¹
- Soy products: Avoid soy products, as they may interfere with thyroid medication absorption.
- Fiber-rich foods: While fiber is essential, high amounts may reduce medication absorption. Take medication at least 30 minutes before or after eating fiber-rich foods.
- Processed foods: Limit foods high in sugar, salt, and unhealthy fats, as they can promote inflammation.
Ginger: Some studies suggest that ginger supplementation may alleviate symptoms of hypothyroidism, but more research is needed.
- Selenium: Selenium supplements may have a beneficial effect on thyroid eye disease, but more research is needed to confirm its effectiveness for Graves' disease.
- Zinc: Zinc supplementation may improve outcomes in people with hypothyroidism, but more research is needed.
Some studies have investigated the effects of dietary interventions on autoimmune thyroid disease. A systematic review and meta-analysis found that dietary interventions may have a beneficial effect on autoimmune thyroid disease, but more research is needed to confirm these findings.²
It's essential to consult with your healthcare provider or a registered dietitian to develop a personalized diet plan that suits your needs with Graves' disease.
[28-03-2025 13:17] Meta AI: https://www.btf-thyroid.org/diets-and-supplements-for-thyroid-disorders
[28-03-2025 13:17] Meta AI: https://www.endocrine-abstracts.org/ea/0070/ea0070aep1106
[28-03-2025 13:17] PPM 1: @Meta AI share the randomized controlled trials listed in that systematic review
[28-03-2025 13:17] Meta AI: The systematic review I mentioned earlier discusses various dietary interventions for autoimmune thyroid disease, including Graves' disease. However, it doesn't explicitly list specific randomized controlled trials (RCTs).¹
That being said, the review does mention that 28 studies were included in the analysis, focusing on different types of dietary supplements and their effectiveness in managing autoimmune thyroid diseases. Some of the interventions mentioned include:
- Selenium supplementation: Improved serum TSH levels and reduced anti-TPO antibody levels.
- Nigella sativa supplementation: Showed improvement in TSH and FT4 levels.
- Myo-inositol and selenium combination: Revealed improvement in FT4 and Anti-Tg antibody levels.
If you're looking for specific RCTs on dietary interventions for Graves' disease, I recommend searching through databases like PubMed or Web of Science using relevant keywords.
[28-03-2025 13:17] Meta AI: https://www.endocrine-abstracts.org/ea/0070/ea0070aep1106
[28-03-2025 21:06] PPM 4: https://pubmed.ncbi.nlm.nih.gov/36598468/
Sir, this full article suggests that a paleolithic diet can help with autoimmune thyroid disorders,
including Hashimoto’s thyroiditis and Grave’s disease.
This is a short summary of the paper:
P: Female patients diagnosed with autoimmune thyroid disease
I: Prescribing a paleolithic diet to these patients
C: Normal standard of care with medication
O: Improved thyroid homeostasis
By a paleolithic diet, this paper refers to:
“Consumption of lean meats, seafood, fruits, vegetables, roots, small amounts of grains and legumes, nuts and seeds, mushrooms and moss.
Excludes: diary and refined food, processed genetically modified and canned foods and ingredients.”
Some statistically significant findings about how this diet influenced outcomes include:
“Significant improvements were identified in one particular case study including a reduction of TSH by 36.4%, Tg Ab by 47.4%, TPO Ab by 28.9%, and an increase in total T4 (T-T4) by 21.5% and total T3 (T-T3) by 33.3% in just 8 weeks. Four studies showed clinical improvement of both HT and GD Ab and resolution of diagnosis over a 12 week to 24 month period; reduction in TSH and TPO Ab, normalized TSH and Tg Ab, and reduction of TPO Ab, resolution of GD diagnosis via negative TSHR Abs and normalization of T4 and T3, and resolution of HT diagnosis via normalization of TSH, and both Tg and TPO Abs. Arick found an improvement in HT Tg Abs. Manousou et al. stated there were not significant differences in TSH, T4, and T3 between groups, but when they did longitudinal analyses, TSH and FT4 increased in the PD group and they found T3 decreases in the PD group after the first 6 months. Additionally, Abbott et al. found no significant changes in HT thyroid hormones or Abs, but noted a significant improvement in health related quality of life (HRQL) and symptom burden. In total, six of the eight studies (75%) showed considerable improvements in both HT and GD Abs and resolution of both HT and GD diagnoses Results may be associated with the level of compliance from study subjects.”
[28-03-2025 21:18] PPM 1: Let's just closely examine a single such study by mentioning
P: total patients in the study
I: how many consumed what diet in each diet group
C: what was contained in the normal diet group and how many persons in that group?
O: Let's just look at resolution of GD diagnosis and not bother about the biochemical improvement because it's ultimately the clinical improvement that would matter
[28-03-2025 21:19] PPM 4: Okay sir
[28-03-2025 22:03] PPM 4: https://europepmc.org/article/med/31476135
Sir, this was one of the references for this article and I thought it was relevant due to the patient’s age and a subsequent pregnancy.
P: 34 year old Caucasiam female
I: Dietary changes, oral health interventions, practice of yoga
C: Since this is a case report of a single person, the comparison was her own previous diet, which primarily included salads, seasonal fruits and meat and quinoa.
O: A progressive improvement of symptoms such as palpitations, weight loss, agitation, tearfulness, and glucose dysregulation (frequent snacking, intense appetite in the morning, only feeling energised by meals). The patient’s low grade hair loss continued to persist, however.
Diet consumed was: meat, fish, eggs, nuts and seeds, fruits and vegetables; while removing processed foods, refined carbohydrates, dairy, gluten. This food could be reintroduced later on in small quantities if desired.
The patient also had a successful pregnancy with the exception of the first trimester, where she had a relapse of her disease, but it was then bought under control and she had no further problems.
The baby was born healthy with no signs of neonatal hyperthyroidism either.
[29-03-2025 07:28] PPM 1: Excellent share 👏👏
How to get the full text?
[29-03-2025 07:55] PPM 1: Seeing this today morning, a journal editor and head neuroscience research
lab, PGI, Chandigarh, wants you all to publish this PaJR patient here in his journal!👇
[29/03, 07:34]aa: Like this please consider submitting N of 1 trials to
[29/03, 07:52]cm: We could. One of our medical students actually reviewed this for a similar patient of
ours yesterday!
[29-03-2025 08:16] PPM 1: While this is a nice serendipitous finding about a single case (with it's
obvious scientific limitations), i meant let's look at a single RCT on the interventions for autoimmune
thyroid disease.
We are currently working on a paper with @~RK @~~M @PPM2 that addresses the current limitations of RCTs, as they are compelled to look at single causes and effects due to reductionist nature of scientific study designs that often manages to remove the whole patient context from the problem they are addressing!
Our current paper is proposing a new design that will be able to tie up every data element in an ontology framework driven by case based reasoning engines and make them flow together in a future AI supported whole-o-graphic ecosystem where every part is embedded in and is found to contain the whole especially when one breaks off different fragments from the whole and finds the whole still contained in the individual broken fragments!
Check out the section basics of holography here:
More about case based reasoning here: https://pmc.ncbi.nlm.nih.gov/articles/PMC544898
[29-03-2025 13:14] PPM 4: Sir, I found the pdf of the article on google scholar
[29-03-2025 13:15] PPM 4: I’ve taken her history sir, I’ll share it by tonight here in the group
[29-03-2025 13:18] PPM 4: Yes, sir. While I haven’t found a proper RCT for Grave’s disease yet, I’ve
seen a couple for Hashimoto’s thyroiditis, can I share those findings here as well?
[29-03-2025 14:38] PPM 1: Share it here
[29-03-2025 14:39] PPM 1: Can
[29-03-2025 14:39] PPM 1: One by one
[29-03-2025 16:32] PPM 1: Now let's write up both of our current Graves disease cases in the format
given here. 👏👏
The case report linked here in the description box as well as another graves disease seen a few weeks back already logged here 👇
And then submit to the editor of jimcr as linked above @~PPM4 @~PPM3 @~~M @~R K
[29-03-2025 16:49] PPM 4: Yes, sir.
I didn’t exactly understand about the format?
[29-03-2025 16:51] PPM 1: See their case report structure, which is how journals want us to share the
patient data and see our conversational PaJR case report format which is different.
So you will need to change our current two case reports into the jimcr journal publishable format. Also
check out the other case reports in the jimcr journal
[29-03-2025 16:54] PPM 1: @PPM5 would be interesting to check if AI can help convert all our current
case reports here👇
into journal publishable format in which case we could retain the current conversational PaJR format
and also add a structured format to each our published PaJR cases?
Also can AI help us to count how many active PaJR cases we have accumulated ever since @CR
logged her first case report in the above link?
[29-03-2025 17:03] PPM 4: Okay sir
[29-03-2025 20:53] PPM 4: CHIEF COMPLAINT:
Palpitations and tremors in hands since five years.
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic five years ago. Then, she became pregnant, around the same time when she noticed that she was having palpitations, coarse tremors and sweating. She also reported feeling tired. Upon visiting the doctor, she was found to have hyperthyroidism, for which she was prescribed Propylthiouracil 50mg by a local practitioner. She has followed up with the practitioner once when she had initially been prescribed the medication, but hasn’t followed up regularly with them after that. One month ago, she has visited the dental hospital where the doctors had referred her to the department of general medicine to assess her apparent goiter and exophthalmos.
MENSTRUAL HISTORY:
Patient attained menarche at 12 years. She has a regular cycle of 5 days for every 28 days, no menorrhagia or dysmenorrhea, sometimes associated with clots.
PAST OBSTETRIC HISTORY:
The patient has two children, who are both alive and healthy.
First child, male, was born four years ago, through LSCS.
Second child, female, was born nine months ago, through LSCS.
The mother has taken the same dose of Propylthiouracil throughout both pregnancies. She reports no exacerbation of symptoms.
MEDICATION HISTORY:
Initially the patient took Propylthiouracil 50mg prescribed by a local practitioner.
After being referred here, her presrciption has changed to Carbimazole 10mg and Propranolol Sustained Release 20mg.
The patient is on no other medication.
PAST HISTORY:
N/K/C/O DM, HTN, TB, Thyroid, Asthma, CAD, CVA
LSCS deliveries in the years 2021 and 2024.
FAMILY HISTORY:
No relevant family history.
PERSONAL HISTORY:
The patient is a home-maker. She appears mentally troubled by her thyroid issue.
Diet- mixed
Appetite- decreased
Sleep- normal
Bowel and bladder- Regular
The patient used to consume toddy occasionally, but stopped doing so after she got married 6 years ago.
[29-03-2025 21:11] M: Who is working on this sir? How can i help?? Please let me know..
[29-03-2025 21:20] PPM 1: @~PPM3 @~PPM4 are working on publishing this in jimcr and you can
join us by helping to restructure it as per the jimcr format! It's already logged here as a PaJR case report
and is regularly updated in the case report link shared here in the description box. There's another
hyperthyroid lady of similar age shared above which can be combined if we can again work on her
current issues further by telephonic communication with the patient @~PPM4
[29-03-2025 22:15] PPM 6: Okay sir
[29-03-2025 22:15] PPM 6: Got it
[29-03-2025 22:15] PPM 6: @~PPM4 @~PPM3 can you guys share me the draft if you have started
forming the manuscript?
[30-03-2025 08:33] PPM 4: We haven’t started yet ma’am, we’ll share once we do!
[30-03-2025 09:24] PPM 6: Sure!
[30-03-2025 13:01] PPM 1: Guess the three of you are all 2021 MBBS batch?
[30-03-2025 13:02] PPM 1: @~PPM5 @~PPM3 when are you going to add the primary patient advocate here?
[30-03-2025 13:04] PPM 4: Sir, the patient’s advocate is already in the group.
I shared a link with them day before yesterday and they joined yesterday.
[30-03-2025 13:08] PPM 1: You mean the patient's primary advocate because we are supposed to keep
the patient deidentified
[30-03-2025 13:13] PPM 4: Yes sir, my mistake
[30-03-2025 15:45] PPM 5: I gave this prompt -
Can you take a look at this blog
And rewrite it in this format
Please read the images in the blog to get all info.
.. and got AI to give this back
Abstract
This case report discusses a 36-year-old female diagnosed with Graves' disease in August 2023. Despite medical management with carbimazole, she presented with persistent symptoms and new developments, including increased thyroid swelling and nail changes. This report examines her clinical presentation, treatment course, and the considerations for managing Graves' disease.
Introduction
Graves' disease is an autoimmune disorder characterized by hyperthyroidism due to circulating autoantibodies. Common symptoms include goiter, ophthalmopathy, and dermopathy. This case highlights the challenges in managing Graves' disease and the importance of monitoring for disease progression and treatment side effects.
Case Report
Patient Information
Age: 36 years
Gender: Female
Diagnosis: Graves' disease (August 2023)
Clinical Presentation
The patient was diagnosed with Graves' disease in August 2023 and initiated on carbimazole 10 mg once daily. She reported increased sweating and, upon examination, exhibited mild eye signs and fine tremors. Over the past year, she noted increased thyroid swelling and nail changes.
Diagnostic Assessment
Specific diagnostic test results, including thyroid function tests (T3, T4, TSH levels), thyroid autoantibodies, and imaging studies, were not detailed in the available information.
Therapeutic Intervention
The patient was prescribed carbimazole 10 mg once daily since her diagnosis. In response to the increased thyroid swelling and persistent symptoms, a discussion among healthcare providers considered increasing the carbimazole dose to 10 mg three times daily, with a review planned in one month.
Follow-Up and Outcomes
Follow-up details, including the patient's response to the adjusted treatment regimen and any changes in clinical or laboratory findings, were not provided in the available information.
Discussion
This case underscores the importance of regular monitoring and timely intervention in managing Graves' disease. The patient's persistent symptoms and new developments, such as increased thyroid swelling and nail changes, prompted consideration of treatment adjustment. The discussion among healthcare providers highlighted the debate over dosing frequency and the potential benefits of once-daily versus divided doses of carbimazole. Studies have shown that a single daily dose of carbimazole can be as effective as divided doses in inducing euthyroidism, with potential benefits for patient compliance.
Conclusion
Effective management of Graves' disease requires individualized treatment plans and ongoing assessment of therapeutic efficacy. This case illustrates the need for clinicians to remain vigilant for signs of disease progression or treatment side effects and to adjust management strategies accordingly.
Consent
The patient's de-identified health data were shared after obtaining her signed informed consent.
References
Frontiers in Endocrinology. "Carbimazole dosing in the treatment of Graves' disease."
Note: This case report is based on limited information provided in the blog post and may not include all
necessary clinical details typically found in comprehensive medical case reports.
[30-03-2025 15:46] PPM 5: Nowhere close to the detail that exists in all the images.. will think about how to extract everything more comprehensively from the blog.
[30-03-2025 15:53] PPM 1: But still a great help!👏👏@~PPM4 @~PPM3 @PPM6 let's do this also for our previous thyrotoxicosis patient whose case report I shared above And then let's submit it to the journal.
What is "integrative medicine" about our work? Well that's again a lot of review of literature that we have already been doing for the conversational commentary that can also be used there
[30-03-2025 15:54] PPM 1: Which LLM? Currently I don't find any LLM reading URLs unless they are
premium versions.
[30-03-2025 16:01] PPM 5: ChatGPT free version only but with the search button selected
[30-03-2025 16:03] PPM 5: I'm experimenting with locally running LLMs on my machine and with agentic AI (using model context protocol MCP), hoping to get better results with that. With MCP, we can ask AI to first fetch the data, then individually look at images and text and then collate all answers from each of the tasks together at the end. Will keep you posted on the experiments. Early stages, images are a challenge.
[30-03-2025 16:04] PPM 1: Looks like the patient's primary advocate left!
We forgot that for primary PaJR patient advocates being in these technical discussions could be problematic and perhaps we need to create two separate PaJR groups for them (one for their data sharing and another for our analysis)!
[30-03-2025 16:05] PPM 5: uh oh! will continue this on the conversational commentry group
[30-03-2025 16:05] PPM 1: Great to hear this
[30-03-2025 16:06] PPM 1: Now that they have left we can continue here and @~PPM4 can
create another PaJR primary data capture group for this patient
[30-03-2025 16:08] PPM 1: In the current commentary perspective it's interesting to note how our
world of two dimensional academic analysis is so much removed from the patient's multi-dimensional
reality!
[30-03-2025 16:09] PPM 1: Bridging this gap is akin to try and make out our hospital area.
syndrome patient's head touch the bed! https://medicinedepartment.blogspot.com/2025/03/project-7-years-in-narketpally.html?m=1
[30-03-2025 16:24] PPM 4: Sir, I just called them up and they don’t have anyone that understand
English in their family, so they got a little overwhelmed and left
I told them I’d explain them what to do, and added them back, but if its easier, I’ll make another group
for them so that its less overwhelming
[30-03-2025 20:45] M: Okay sir, we can include a timeline flowchart and patient reported outcomes if
atleast 1 figure and 1 table is allowed… it will give a multidimensional realisitic capture as experienced
by the patient + our 2D analysis :))
[30-03-2025 20:46] PPM 2: @Meta AI have we vetted this in patient centered trials?
[30-03-2025 20:46] Meta AI: To answer your question accurately, I need more context about the
specific treatment or intervention you're referring to. Can you please provide more details or clarify
what you mean by "this"?
[30-03-2025 20:47] PPM 2: @Meta AI that avoiding such foods actually improves Graves disease
[30-03-2025 20:47] Meta AI: There is limited research on the impact of specific diets on Graves'
disease. However, some studies suggest that avoiding foods that trigger inflammation or impair thyroid
function may help alleviate symptoms.
Here are some foods that may be beneficial to avoid:
1. Gluten: Some people with Graves' disease may have a gluten intolerance or sensitivity, which can exacerbate symptoms.
2. Soy: Soy products contain isoflavones, which may interfere with thyroid function.
3. Raw cruciferous vegetables: While cooked cruciferous vegetables are nutritious, raw ones contain goitrogens, which may impair thyroid function.
4. Processed foods: Processed foods often contain unhealthy ingredients, added sugars, and sodium, which can worsen inflammation.
Keep in mind that everyone's experience with Graves' disease is different, and it's essential to consult with a healthcare professional before making significant changes to your diet.
[30-03-2025 20:47] PPM 2: @Meta AI please share a patient centered trial to support your hypothesis
[30-03-2025 20:47] Meta AI: Unfortunately, I couldn't find a specific patient-centered trial that supports the hypothesis that avoiding certain foods improves symptoms of Graves' disease. However, there are some studies and guidelines that discuss the importance of diet and lifestyle changes in managing Graves' disease.
Dietary Considerations for Graves' Disease
- Some studies suggest that avoiding foods that trigger inflammation or impair thyroid function may help alleviate symptoms ¹.
- Foods that may be beneficial to avoid include gluten, soy, raw cruciferous vegetables, and processed foods.
Lifestyle Changes for Graves' Disease
- Quitting smoking and reducing stress may also help manage symptoms ¹.
- Getting regular exercise and maintaining a healthy weight can also improve overall health.
If you're looking for more information on patient-centered trials or studies on Graves' disease, I recommend searching through reputable sources such as the National Institutes of Health (NIH) or the American Thyroid Association (ATA).
[30-03-2025 20:47] Meta AI: https://www.ncbi.nlm.nih.gov/books/NBK448195/
[30-03-2025 20:52] PPM 2: @PPM6 what is the current situation with the patient at the moment?
[30-03-2025 21.46] PPM 1: Thanks @~PPM4 @~PPM3 We can ask @~PA to share her daily hourly
activities and food plates?
[30-03-2025 21:46] PPM 6: Hello sir, I’m based in Indore 😅 so don’t know if you are asking about the real time update..
[30-03-2025 21:48] PPM 2: Oh I see. I thought you were aware of the patient's current status.
Apologies.
[30-03-2025 21:48] PPM 6: No worries sir :)
[30-03-2025 22:13] PPM 1: @~PPM4 @~PPM3 can answer this as they are the ones who handled the
patient from our hospital campus and are still in touch.
Our integrative medicine case report may not be about diet or lifestyle modification as much as it could be about cultural integration!
""integrative medicine is essentially an application of different “culturally sensitive” health care approaches, optimally tailored to a given patient's needs and difficulties.
Efforts are needed at the clinical, research, and administrative levels to reduce the “othering” phenomenon seen in health care approaches that are often detrimental to efficient patient care.
There is a need to promote collaboration between different disciplines and generate evidence base to optimize integrative medical practice further."
@PPM6 @~PPM4 this will be the pivotal introduction to our integrative case report on our current two
patients of thyrotoxicosis.
Who shall form the other patient's PaJR and gather current data? She had another interesting issue of
painful penicillin prophylaxis that we stopped!
[30-03-2025 22.36] PPM 4: Yes sir, I’ll get in touch with her again to do so.
[30-03-2025 22:42] PPM 4: Sir, currently she’s on Carbimazole 10mg thrice daily and
Propranolol sustained release 20mg once daily.
Upon talking to her, she doesn’t really report any symptoms bothering her, the way she said they did
before she was taking any form of medication at all, but she does seem a little mentally troubled by her
problem.
If there’s anything specific I couldn’t clarify, please let me know so I can get back about it more
accurately :)
[30-03-2025 22:44] PPM 4: Sir, I can get in touch with the other patient and make a PaJR for her.
[30-03-2025 23:08] PPM 1: That would be great. @CR has her consent form that has her number and I guess you have already seen her link to the case report
[30-03-2025 23:09] PPM 1: When did she start having symptoms and after how many days of that did
she start medication and what dose for how long?
PPM 1: 👍
[31-03-2025 08:22] PPM 4: Okay sir, I will get in touch with them.
[31-03-2025 08:26] PPM 1: Yes if you see the first prescription image in her case report dated January
2021 you will find mentioned as post partum.
Let's also add this initial history narrative text in the case report beginning @CR
Let's elaborate her events sequences
What were her thyroid function tests like since 2021?
[31-03-2025 09:05] PPM 1: She never had normalisation of her thyroid profile and yet remained asymptomatic?
Can we have an event timeline of her symptoms as to when did she actually experience her symptoms
of thyrotoxicosis and when was she symptoms free?
[31-03-2025 12:49] PPM 2: And has she ever gotten tested for antibodies? Not for diagnosis but will
need it for future pregnancy if planning.
[31-03-2025 12:51] PPM 1: She had her initial illness during her first pregnancy and the second
pregnancy happened unnoticed with no issues at delivery of the second
[31-03-2025 12:53] PPM 2: Serendipity! Might as well check.[31-03-2025 12:53] PPM 2: But no eye signs I hope
[31-03-2025 12:55] PPM 1: Very much present. Check the video taken by @~PPM3 and uploaded by @CR
[31-03-2025 12:55] PPM 2: Oh yes now I remember. Yes then we should perhaps get antibodies checked.
[31-03-2025 12:55] PPM 2: TPO and TRAbs
[31-03-2025 13:00] PPM 1: How will that help? Let's assume they are positive as in a chess game. What would we do next differently than what we are doing now?
[31-03-2025 13.17] PA: Lunch
[31-03-2025 15:11] PPM 4: Yes sir, even when I was asking her if she had any symptoms currently, she said that she had no problem with any of the typical symptoms, like palpitations or sweating.
As she got pregnant the first time, she started to feel palpitations, for which she went to the doctor. After
that, she said she started to feel better gradually, and she’s currently asymptomatic now.
[31-03-2025 18:04] PPM 1: Since when is she asymptomatic?
[31-03-2025 19:40] PPM 4: Sir, she said she was asymptomatic ever since she was started on Propylthiouracil, she found that her symptoms disappeared gradually over a period of time and then hasn’t experienced them since.
[31-03-2025 20:15] PPM 1: Asymptomatic since 2021?
[31-03-2025 21:08] PPM 4: Yes sir
[01-04-2025 08.30] PA:
[01-04-2025 08.40] PPM 1: 👍
[01-04-2025 13.37] PA: Lunch
[01-04-2025 14.38] PPM 1: 👍
[02-04-2025 08.51] PA: Breakfast
Lunch at 12.52
[02-04-2025 13.10] PPM 1: 👍
[03-04-2025 13.10] PA: Lunch
PPM 1: 👍
[04-04-2025 08.56] PA: Breakfast
[04-04-2025 13.41] PA: Lunch
[06-04-2025 13:54] PPM 4: Sir, here are some RCTs I found with different dietary interventions and supplementations that might help with autoimmune thyroid disease.
These are mostly for Hashimoto's thyroiditis, I wasn't able to find many for Grave's disease.
[06-04-2025 13:57] PPM 4: "After supplementation, the serum levels of 25(OH) D and calcium increased significantly and the levels of TSH and anti-Tg Ab decreased significantly in the vitamin D group compared to baseline. However, in the placebo group, the serum Level of T4 decreased significantly compared to baseline. There was none significant reduction of anti-TPO Ab in Vitamin D group compared to placebo group. The levels of anti-TPO Ab and anti-Tg Ab decreased by 15.3 and 28.2% in vitamin D-supplemented group, respectively. Vitamin D did not affect the serum levels of T3 and T4"
This paper refers to the supplementation of Vitamin D and how it helped reduce TSH levels. However, T3 and T4 levels weren't really affected and the study itself says that longitudinal association needs to be studied.
[06-04-2025 14:06] PPM 4: https://pubmed.ncbi.nlm.nih.gov/28724185/
In this study, the placebo group received only selenium whereas the study group received both myo-inositol and selenium. The study group reported a symptomatic improvement as well as improved lab findings. This was undertaken because selenium was found to decrease the autoantibodies, and myoinositol is an important second messenger for TSH, FSH and LH.
[06-04-2025 14:06] PPM 1: Yes so, this study didn't help much although it must've taken a lot of resources!
@Meta AI please share your thoughts on this increasingly common entity called 'research waste'
[06-04-2025 14:06] Meta AI: Research waste refers to the phenomenon where resources invested in research, such as time, funding, and effort, do not generate the expected benefits or impact. This can occur due to various reasons, including:
1. Lack of clear research questions or objectives
2. Poor study design or methodology
3. Inadequate or incomplete data collection
4. Failure to publish or share research findings
5. Duplication of existing research without adding new insights
To address research waste, researchers, funders, and publishers are exploring strategies such as:
1. Registering research protocols and sharing data
2. Encouraging collaboration and knowledge-sharing
3. Implementing more rigorous study design and reporting standards
4. Supporting open-access publishing and dissemination of research findings
By acknowledging and addressing research waste, we can optimize the use of resources, improve research quality, and ultimately accelerate progress in various fields.
[06-04-2025 14:07] PPM 4: I'm also looking for studies that are more routine dietary intervention based rather than supplementations, sir
[06-04-2025 14:07] PPM 1: We need to know the details of their symptomatic improvement and lab findings in contrast to the placebo group
[06-04-2025 14:13] PPM 4: "There was a significant decrease in mean TPOAb concentrations in group
B (from 733.7 ± 485.8 IU/ml to 614.4 ± 472.0
IU/ml, (p ≤ 0.05). The mean values of serum
TPOAb concentrations in group A decreased
from 820.13 ± 513.99 IU/ml to 724.51 ± 524.98
IU/ml, but the decrement was not significant.
Significance was observed in the comparison between values obtained after six months administration in treated vs. controls (p ≤ 0.05).
A significant improvement of SS was reached
among all patients. The questionnaire score
showed a lowering from 4.71 ± 0.83 at baseline
to 2.42 ± 0.81 post-treatment in combined MI-Se
patients (p ≤ 0.001), and from 4.6 ± 0.63 at beginning to 2.75 ± 0.62 at the end of the study in
Se-patients (p ≤ 0.001). One-way ANOVA revealed a significant variance between group A
and group B after treatment"
Group B is the study group, sir.
By SS, they mean 'subjective sympotomatology'.
For symptomatic improvement, the study said that they issued a questionnaire to the participants, but the details of the questionnaire were not shared within the study.
[06-04-2025 14:18] PPM 1: Thanks!
The TpOAb numbers change don't appear to be clinically significant and that is always more important than statistical significance (journals always try to mislead and sell by playing on statistical significance)!
How the subjective symptomatology score was done is very important to know.
Let's start working on your case report discussion where we will mention the above current learning points on nutritional interventions in thyroid inflammatory states and their inefficacy and the role of these learning put in the patient's overall illness outcomes (less pills to swallow)
[06-04-2025 14:45] PPM 4: Yes sir. We’ll be starting the draft tomorrow and we’ll keep you updated about it accordingly sir.
PPM 1 - 👍
[08-04-2025 12.28] PA: 2 puri's, curry and Juice
[08-04-2025 16.16] PA: Papaya
[09-04-2025 13.39] PA: Lunch rice with aloo
[14-04-2025 13.06] PA: Lunch rice with curry and chips
PPM 1: 👍
[15-04-2025 13.52] PA: Lunch rice with one boiled egg and chutney
PPM 1: 👍
[18-04-2025 13.27] PA: Lunch rice with dal and papad.
PPM 1: 👍
[02-05-2025 11.13] PPM 1: Reviewing now in OPD. All well
Asymptomatic as before although father complains of increased anger issues.
On carbimazole 20mg-10mg-20mg
Last TFT was double T4 with normal T3 and TSH<0.001
Clinically near euthyroid with persistent eye signs. Notice the koilonychia in the images.
[03-05-2025 11.21] PA: 
[03-05-2025 11:21] PPM 1: Thanks
[03-05-2025 11:24] PPM 1: @PA దయచేసి అదే థైరాయిడ్ మందులను మరో నెల పాటు అదే మోతాదులో కొనసాగించండి మరియు ఆమెకు ఇనుము లోపం ఉన్న రక్తహీనత కోసం రోజుకు ఒకసారి లివోజెన్ (ఫెర్రస్ ఫ్యూమరేట్) 120 mg టాబ్లెట్ను జోడించండి.
Dayacēsi adē thairāyiḍ mandulanu marō nela pāṭu adē mōtādulō konasāgin̄caṇḍi mariyu āmeku inumu lōpaṁ unna raktahīnata kōsaṁ rōjuku okasāri livōjen (pherras phyūmarēṭ) 120 mg ṭābleṭnu jōḍin̄caṇḍi.
Please continue the same thyroid medications in the same dose for another month and also add tablet Livogen (Ferrous Fumarate)120 mg once daily for her iron deficiency anemia.
[13-06-2025 11.15] PPM 1: Reviewing now in OPD
Apparently All well
Asymptomatic as before although father complains of increased anger issues.
The anger hasn't increased or decreased but is similar and father is still upset about it. Husband left her since 1 year and father says since her marriage five years back she hasn't stayed with him for more than 1 year, intermittently coming back home!
Can all these be explained by her thyrotoxicosis? @Aditya
On carbimazole 20mg-10mg-20mg
Last TFT was double T4 with normal T3 and TSH<0.001
Clinically near euthyroid with persistent eye signs. Notice the koilonychia in the images.
[13-06-2025 11:19] PPM 1: @PPM6 @PPM4 your project!
[13-06-2025 11:21] PPM 1: @PPM9 can @PA call you at your convenience for this patient's anger issues?
Please let him know what time would be convenient
[13-06-2025 11:45] PPM 9: Sure Sir
[13-06-2025 12:38] PPM 1: Thanks. Please let him know your convenient time
[13-06-2025 14:29] PPM 6: Yes sir
[13-06-2025 14:29] PPM 6: We are a bit slow, sorry sir 😅
[13-06-2025 15.30] PPM 1: Today's report: Still leucopenic but clinically no agranulocytosis features
How do we differentiate simple neutropenia from significant agranulocytosis?
What should we do with the dose? That will also depend on her current thyroid profile. @PPM7 when do we get that?
[13-06-2025 16:02] PPM 1: @PPM7 reduce carbimazole to tid
[13-06-2025 16:09] PPM 7: she is using Tid dose sir
[13-06-2025 16:13] PPM 10: Based on the clinical details provided, here's a breakdown of how the symptoms and social situation relate to thyrotoxicosis:
1. *Anger Issues:*
* *Possible Connection:* Irritability, emotional lability, anxiety, and mood swings (including anger outbursts) are *very common neuropsychiatric symptoms of thyrotoxicosis*. Hyperthyroidism significantly impacts the central nervous system and can make individuals feel "wired," easily frustrated, and short-tempered.
* *Current Status:* The report states the anger is "similar" and hasn't actually increased, though the father is understandably upset by it. The fact she is "clinically near euthyroid" but still has significant anger issues while biochemical control is still poor (high FT4, suppressed TSH) strongly suggests *the persistent thyrotoxicosis is the primary driver of these mood symptoms*. Achieving true biochemical euthyroidism (normal TSH, FT4, FT3) is essential for resolving this.
2. *Marital Instability & Living Situation:*
* *Possible Contribution:* The chronic mood disturbances (anger, irritability, anxiety) caused by poorly controlled thyrotoxicosis over the past 5 years could certainly *contribute significantly to marital discord and relationship breakdown*. Living with someone experiencing these unpredictable mood changes can be extremely challenging.
* *Not Sole Explanation:* While thyrotoxicosis likely played a major role, it's unlikely to be the only factor. Marriage involves complex interpersonal dynamics, compatibility, communication, and external stressors. Attributing the entire marital history solely to thyroid disease oversimplifies it. The thyroid dysfunction was a major stressor, but other factors were likely involved.
3. *Koilonychia:*
* *Unlikely Direct Connection:* Koilonychia (spoon-shaped nails) is *not a typical feature of thyrotoxicosis. Its primary association is with **iron deficiency anemia*.
* *Possible Indirect Link:* While not directly caused by hyperthyroidism, potential contributing factors could include:
* *Concurrent Iron Deficiency:* Very common, especially in women. Requires investigation (CBC, ferritin).
* *Malabsorption/Nutritional Issues:* Severe, long-standing thyrotoxicosis can increase metabolic demands and potentially impact nutrition, but this is less common with modern treatment. Koilonychia strongly points to needing iron studies.
4. *Thyroid Status & Management:*
* *Biochemical Control:* The TFT (high FT4, suppressed TSH) confirms she is *still significantly thyrotoxic* despite being clinically "near euthyroid." This discrepancy highlights that subjective clinical assessment isn't always reliable, and biochemical testing is crucial. Normal T3 is common on treatment as conversion is often blocked first.
* *Carbimazole Dosing (20-10-20):* This alternating pattern is unusual and likely *suboptimal. It risks under-treatment on the 10mg days, hindering achievement of biochemical control. **Recommendation:* Standard practice is consistent daily dosing. The dose needs adjustment based on TFTs. With persistent thyrotoxicosis on this regimen, an *increase in daily dose* (e.g., consistent 20mg or possibly 30mg daily) is warranted, followed by repeat TFTs in 4-6 weeks. *Adherence* should also be gently explored.
* *Persistent Eye Signs:* Consistent with Graves' disease (the most common cause of thyrotoxicosis with eye involvement).
*Summary & Recommendations:*
* *Anger Issues:* Highly likely *driven by persistent biochemical thyrotoxicosis*. Optimizing medical control is essential.
* *Marital Situation:* Thyrotoxicosis-related mood symptoms were a *significant contributing factor* to the marital discord and instability over the past 5 years, but unlikely the sole cause.
* *Koilonychia:* *Not related to thyrotoxicosis.* Strongly suggests *iron deficiency anemia*. Requires urgent investigation (CBC, ferritin).
* *Thyroid Management:*
* *Adjust Carbimazole:* Increase dose (e.g., consistent 20-30mg daily) to achieve biochemical euthyroidism.
* *Repeat TFTs:* In 4-6 weeks after dose adjustment.
* *Check Adherence:* Discuss medication routine.
* *Investigations:*
* *Iron Studies:* CBC, Ferritin (for koilonychia).
* Consider TRAb or TSI if Graves' diagnosis isn't confirmed.
*In conclusion:* The anger issues are directly explicable by the poorly controlled thyrotoxicosis. The marital instability was significantly influenced by the chronic mood symptoms of the disease. The koilonychia requires separate investigation for iron deficiency. *Urgent priorities are optimizing carbimazole dose to control the thyroid and investigating/treating iron deficiency.* Addressing the biochemical control is the most critical step for improving her mood and overall well-being.
[13-06-2025 16:14] PPM 1: She was taking 2-1-1
Make it 2-1-0
Yes not tid, bid 👍
[13-06-2025 16:16] PPM 10: Based on the hemogram report and the clinical context, here's an integrated analysis and urgent management plan:
### Critical Findings in Hemogram:
1. *Severe Microcytic Hypochromic Anemia:*
* Hb 10.4 g/dL (low), MCV 61.4 fL (very low), MCH 19.2 pg (very low), MCHC 31.2% (low).
* *Confirms Iron Deficiency:* Explains the observed koilonychia. Requires *urgent treatment*.
2. *Leucopenia:*
* WBC 3000 cells/µL (low) with "decreased counts on smear."
* *High-Risk for Carbimazole:* This is a *medical emergency* due to risk of agranulocytosis, even if asymptomatic now.
3. *Thrombocytopenia:*
* Platelets 2.8 lakhs/µL (low-normal but concerning in context).
4. *RDW Elevated (23.7%):*
* Suggests anisocytosis, typical of active iron deficiency or mixed anemia.
### Urgent Management Priorities:
1. *Immediate Carbimazole Adjustment:*
* *STOP carbimazole immediately* due to significant leucopenia.
* *Alternative thyroid control:*
* *Beta-blockers:* High-dose propranolol (e.g., 40mg TDS) for symptom control (tachycardia, tremor, anxiety).
* *Consider Potassium Iodide (SSKI):* Short-term use (e.g., 5 drops BD) to rapidly inhibit thyroid hormone release.
* *Steroids:* Hydrocortisone or prednisolone can block T4-to-T3 conversion and support blood counts.
* *Definitive therapy:* Plan for *early thyroidectomy* or *radioiodine (RAI)* once stabilized (RAI contraindicated if severe eye disease).
2. *Treat Iron Deficiency Anemia Aggressively:*
* *Parenteral Iron:* Preferred due to severity (e.g., IV Ferric Carboxymaltose 1000mg). Oral iron will be slow and poorly absorbed in thyrotoxicosis.
* *Investigate Cause:* Stool for occult blood, endoscopy if GI symptoms. Rule out menorrhagia.
3. *Hematology Support:*
* *Granulocyte Colony-Stimulating Factor (G-CSF):* Consider if neutropenia worsens or fever develops.
* *Monitor closely:* Daily CBC if hospitalized, or every 2-3 days if outpatient.
4. *Thyrotoxicosis & Mood:*
* Persistent biochemical thyrotoxicosis (↑FT4, ↓TSH) is likely exacerbating anger/anxiety.
* *Beta-blockers* will help acutely with adrenergic symptoms (including emotional lability).
### Summary of Key Issues:
| *Issue* | *Cause* | *Action* |
|--------------------|---------------------------------------------------------------------------|----------------------------------------------------------------------------|
| *Leucopenia* | Likely carbimazole-induced (high risk) + possible thyrotoxic marrow suppression | *Stop carbimazole immediately.* Start alternative therapy (SSKI/steroids). Monitor CBC closely. |
| *Severe Anemia* | Iron deficiency (koilonychia-confirmed) | *IV Iron infusion.* Investigate for bleeding/nutritional causes. |
| *Thyrotoxicosis* | Poorly controlled Graves' disease | Alternative meds (SSKI/steroids + beta-blockers). Plan definitive therapy. |
| *Anger/Mood* | Combined effect of thyrotoxicosis + anemia + psychosocial stress | Optimize thyroid/anemia treatment + counseling support. |
### Next Steps:
1. *Hospitalize* for monitoring if feasible (due to leucopenia + severe anemia).
2. *Repeat CBC + Absolute Neutrophil Count (ANC)* now.
3. *Start IV iron* and *initiate SSKI + beta-blocker*.
4. *Thyroidectomy referral* for definitive management once stable.
5. *Educate family:* Agitation may persist until thyroid/anemia improve. Fever/sore throat = emergency.
*This patient requires urgent intervention to prevent agranulocytosis and correct severe anemia while controlling thyrotoxicosis.* Close coordination between endocrinology and hematology is essential.
[13-06-2025 16:16] PPM 1: Carbimazole dosing is daily not on alternate days. It's a daily dose of 20-10-10 mg
[13-06-2025 16:16] PPM 7: patient is not near OPD, I think they left
[13-06-2025 16:19] PPM 1: 👆@PPM10 check out this report from one month back! Is there a therapeutic window with leucopenia she's riding on without developing agranulocytosis complications?
[13-06-2025 16:21] PPM 1: I explained it to them. They are here in this group.
Although I agree with @PPM10 and LLM that letting her continue carbimazole is risky inspite of her having managed to pull it off for one month.
Let's quickly decide what alternative do we have to carbimazole and then phone the advocate
[13-06-2025 16:22] PPM 10: Based on the report, this patient is in a *high-risk hematological state with significant cytopenias, but **not currently in agranulocytosis*. Here's the breakdown:
### Key Findings & Risks:
1. *Severe Leucopenia:*
* *Total WBC: 2,600 cells/µL* (Normal: 4,000-10,000). This is significantly low.
* *Neutrophils: 56%* of 2,600 ≈ *1,456 cells/µL* (Normal Absolute Neutrophil Count (ANC) usually >1,500, mild neutropenia 1,000-1,500, moderate 500-1,000, severe <500).
* *Smear Confirmation:* "WBC counts decreased on smear".
* *Risk:* The ANC (~1,456) is in the *mild neutropenia* range. While not agranulocytosis (ANC <500), it significantly increases infection risk.
2. *Severe Microcytic Hypochromic Anemia:*
* Hb: 7.7 g/dL (Severe anemia, Normal F: 12.0-15.0).
* RBC Indices (Low MCV, MCH, MCHC), High RDW, RBC Morphology: Classic iron deficiency anemia pattern. The elevated RBC count (4.93 mil) is unusual for severe IDA and warrants investigation (e.g., thalassemia trait?).
3. *Thrombocytopenia:*
* Platelets: 2.80 lakhs/mm³ (280,000/µL) (Low-normal/Borderline low, Normal: 150,000-410,000).
4. *Severe Hyperthyroidism:*
* *TSH: 0.002 µIU/mL* (Suppressed << Normal 0.34-5.36)
* *T4: 15.97 µg/dL* (Elevated > Normal 6.32-12.23)
* T3: Normal (1.30 ng/mL). This pattern (High T4, Suppressed TSH, Normal T3) is classic for hyperthyroidism, likely Graves' disease. *Hyperthyroidism itself can cause bone marrow suppression leading to cytopenias (anemia, leucopenia, thrombocytopenia).*
### Addressing "Therapeutic Window" & Agranulocytosis Risk:
* *Current State:* The patient has *mild neutropenia (ANC ~1,456)* secondary to at least severe iron deficiency anemia and hyperthyroidism. This is *not* agranulocytosis.
* *"Riding on" a Window?* This is *highly precarious, not stable. The cytopenias are severe and likely worsening due to the underlying conditions (especially untreated hyperthyroidism). There is **no safe "window" to exploit here*.
* *Agranulocytosis Risk:*
* *Untreated Hyperthyroidism:* Continued hyperthyroidism can worsen bone marrow suppression, potentially driving the ANC lower.
* *Antithyroid Drug (ATD) Therapy (Methimazole/PTU):* *This is the critical risk factor.* ATDs are a *major cause* of drug-induced agranulocytosis. Starting ATDs with pre-existing leucopenia/neutropenia *significantly increases the risk* of precipitating agranulocytosis.
* *Other Causes:* Other drugs (if any), infections, or progression of the underlying marrow issue could also cause a drop.
### Therapeutic Imperatives & Management:
1. *URGENT Thyroid Management:* This is paramount.
* *ATDs are HIGH RISK with this WBC count.* Starting them requires extreme caution and intensive monitoring.
* *Definitive Therapy (Radioiodine or Surgery):* Given the hematological instability, *definitive therapy (RAI or thyroidectomy) is often the preferred first-line approach* over ATDs in this scenario to avoid ATD-induced agranulocytosis risk. *Consultation with Endocrinology and Hematology is essential immediately.*
* *If ATDs Must Be Used:*
* Requires very close monitoring (CBC 1-2 times weekly initially).
* Patient MUST be educated on agranulocytosis symptoms (fever, sore throat, mouth ulcers) and seek immediate care if they occur.
* Lowest possible effective dose.
* High risk of needing to stop ATDs quickly if counts drop further.
2. *Iron Deficiency Anemia Treatment:*
* *Urgent Iron Replacement:* Oral or potentially IV iron therapy is needed. IV may be faster, especially given the severity.
* *Address Cause:* Investigate the cause of iron deficiency (e.g., GI blood loss, menstrual).
3. *Leucopenia/Neutropenia Management:*
* *Infection Precautions:* Meticulous hygiene, avoid crowds/sick contacts, monitor for fever/infection signs closely.
* *Monitor CBC Frequently:* Track WBC and ANC trends closely, especially during any treatment initiation.
* *Growth Factors (G-CSF):* May be considered in specific high-risk situations or if ANC drops severely, but not typically first-line here. Requires specialist input.
4. *Thrombocytopenia Monitoring:* Monitor platelet count, though currently the least critical issue.
### Conclusion:
There is *no safe "therapeutic window" to exploit* with this degree of leucopenia and underlying severe hyperthyroidism + anemia. The patient is in a *high-risk, unstable state. The primary therapeutic challenge is managing the hyperthyroidism **without* precipitating ATD-induced agranulocytosis on a background of pre-existing mild neutropenia.
*Definitive thyroid treatment (RAI or surgery) is strongly preferred over initiating ATDs in this context.* Immediate, coordinated care by Endocrinology and Hematology is crucial. Aggressive treatment of the iron deficiency anemia is also essential. *Close monitoring for infection and serial CBCs are mandatory.* The risk of progressing to agranulocytosis is significant if ATDs are started or if the underlying conditions worsen.
[13-06-2025 16:26] PPM 10: Based on the critical context that *the patient is ALREADY on carbimazole and has been for 1 month* with this severe baseline neutropenia (ANC ~1,456) and uncontrolled hyperthyroidism (TSH suppressed, T4 high), *continuing carbimazole is extremely high-risk and alternatives MUST be prioritized immediately.*
### Urgent Therapeutic Alternatives to Carbimazole
Given the pre-existing leucopenia/neutropenia, *carbimazole should be discontinued TODAY* due to the high risk of precipitating agranulocytosis. Alternatives:
1. *DEFINITIVE THYROID ABLATION (PREFERRED):*
- *Total Thyroidectomy:* *Strongly recommended* as the safest option. Avoids bone marrow suppression risks. Requires urgent surgical referral.
- *Radioactive Iodine (RAI):* Effective but takes 2-3 months to work. Requires isolation and may transiently worsen hyperthyroidism. *Not ideal with severe anemia/neutropenia.*
2. *IMMEDIATE BRIDGE THERAPY (While arranging ablation):*
- *High-Dose IV Corticosteroids:*
- *e.g., Hydrocortisone 100mg IV 8-hourly OR Dexamethasone 4mg IV 12-hourly.*
- Mechanism: Rapidly inhibits peripheral T4-to-T3 conversion, reduces thyroid hormone release.
- Advantage: No bone marrow toxicity.
- Risk: May worsen glucose control/immunity (but safer than agranulocytosis).
- *Beta-Blockers (Maximal Dose):*
- *e.g., Propranolol 40-80mg 6-hourly (or IV if NPO).*
- Critical for symptom control (tachycardia, tremor).
- *Iodine (Lugol's Solution):*
- *5 drops PO 8-hourly* (short-term use only, pre-op or pre-RAI).
- Use cautiously: Can cause "iodine escape" if delayed ablation.
3. *Second-Line Agents (Use if steroids contraindicated):*
- *Cholestyramine (4g 2-4x daily):* Binds thyroid hormone in gut.
- *Lithium Carbonate (300mg 8-hourly):* Inhibits hormone release (monitor levels).
- Note: Less reliable than steroids/beta-blockers.
### Action Plan for the Advocate & Team
1. *Discontinue carbimazole IMMEDIATELY.*
2. *Start bridge therapy TODAY:*
- *IV Steroids + High-dose oral beta-blocker* (unless contraindicated).
3. *Urgent consults:*
- *Endocrine surgery* (for thyroidectomy within 24-48h).
- *Hematology* (for neutropenia management: G-CSF may be needed if ANC drops <1000).
4. *STAT labs NOW:*
- *CBC with differential* (current ANC status is critical).
- *Liver/Renal function, electrolytes* (for surgery/steroid clearance).
5. *Advocate discussion points:*
- "Continuing carbimazole risks fatal agranulocytosis. Her neutropenia was already severe before starting it."
- "Emergency thyroidectomy is the safest option to cure hyperthyroidism without further bone marrow suppression."
- "Bridge therapy with IV steroids will stabilize her until surgery."
- "Delaying action risks life-threatening infection or thyroid storm."
### Key Risks if Carbimazole Continues
- *Agranulocytosis risk:* Estimated 0.2-0.5% on carbimazole, but *skyrockets with pre-existing neutropenia*. Mortality up to 5-10% if sepsis occurs.
- *Thyroid storm:* Uncontrolled hyperthyroidism + stress (e.g., infection) could trigger this fatal crisis.
- *Worsening cytopenias:* Anemia/thrombocytopenia may deteriorate further.
*This is a medical emergency.* Do not wait for symptoms – act now. Her "success" on carbimazole for 1 month is luck, not safety. The next dose could be the one that triggers irreversible bone marrow failure.
[13-06-2025 16:26] PPM 10: Based on the critical context that *the patient is ALREADY on carbimazole and has been for 1 month* with this severe baseline neutropenia (ANC ~1,456) and uncontrolled hyperthyroidism (TSH suppressed, T4 high), *continuing carbimazole is extremely high-risk and alternatives MUST be prioritized immediately.*
### Urgent Therapeutic Alternatives to Carbimazole
Given the pre-existing leucopenia/neutropenia, *carbimazole should be discontinued TODAY* due to the high risk of precipitating agranulocytosis. Alternatives:
1. *DEFINITIVE THYROID ABLATION (PREFERRED):*
- *Total Thyroidectomy:* *Strongly recommended* as the safest option. Avoids bone marrow suppression risks. Requires urgent surgical referral.
- *Radioactive Iodine (RAI):* Effective but takes 2-3 months to work. Requires isolation and may transiently worsen hyperthyroidism. *Not ideal with severe anemia/neutropenia.*
2. *IMMEDIATE BRIDGE THERAPY (While arranging ablation):*
- *High-Dose IV Corticosteroids:*
- *e.g., Hydrocortisone 100mg IV 8-hourly OR Dexamethasone 4mg IV 12-hourly.*
- Mechanism: Rapidly inhibits peripheral T4-to-T3 conversion, reduces thyroid hormone release.
- Advantage: No bone marrow toxicity.
- Risk: May worsen glucose control/immunity (but safer than agranulocytosis).
- *Beta-Blockers (Maximal Dose):*
- *e.g., Propranolol 40-80mg 6-hourly (or IV if NPO).*
- Critical for symptom control (tachycardia, tremor).
- *Iodine (Lugol's Solution):*
- *5 drops PO 8-hourly* (short-term use only, pre-op or pre-RAI).
- Use cautiously: Can cause "iodine escape" if delayed ablation.
3. *Second-Line Agents (Use if steroids contraindicated):*
- *Cholestyramine (4g 2-4x daily):* Binds thyroid hormone in gut.
- *Lithium Carbonate (300mg 8-hourly):* Inhibits hormone release (monitor levels).
- Note: Less reliable than steroids/beta-blockers.
### Action Plan for the Advocate & Team
1. *Discontinue carbimazole IMMEDIATELY.*
2. *Start bridge therapy TODAY:*
- *IV Steroids + High-dose oral beta-blocker* (unless contraindicated).
3. *Urgent consults:*
- *Endocrine surgery* (for thyroidectomy within 24-48h).
- *Hematology* (for neutropenia management: G-CSF may be needed if ANC drops <1000).
4. *STAT labs NOW:*
- *CBC with differential* (current ANC status is critical).
- *Liver/Renal function, electrolytes* (for surgery/steroid clearance).
5. *Advocate discussion points:*
- "Continuing carbimazole risks fatal agranulocytosis. Her neutropenia was already severe before starting it."
- "Emergency thyroidectomy is the safest option to cure hyperthyroidism without further bone marrow suppression."
- "Bridge therapy with IV steroids will stabilize her until surgery."
- "Delaying action risks life-threatening infection or thyroid storm."
### Key Risks if Carbimazole Continues
- *Agranulocytosis risk:* Estimated 0.2-0.5% on carbimazole, but *skyrockets with pre-existing neutropenia*. Mortality up to 5-10% if sepsis occurs.
- *Thyroid storm:* Uncontrolled hyperthyroidism + stress (e.g., infection) could trigger this fatal crisis.
- *Worsening cytopenias:* Anemia/thrombocytopenia may deteriorate further.
*This is a medical emergency.* Do not wait for symptoms – act now. Her "success" on carbimazole for 1 month is luck, not safety. The next dose could be the one that triggers irreversible bone marrow failure.
[13-06-2025 16:32] PPM 1: That means we may have to call her to get ready for thyroidectomy @PPM7 @CR
While we do that here's a case report of a woman with thyrotoxicosis and on carbimazole where a review of past blood results showed that she had neutropenia for the entire four years of treatment with no incidence of infection!
I guess there would be a lot many more such patients who are riding riskily if only we had access to their data? @PPM5 @PPM2 @PPM8
[13-06-2025 17:07] PPM 1: Unfortunately no previous hemograms in her case report! @PPM7 @CR can the advocate be called @PA @123 and asked to share the previous hemogram reports in her PaJR? Also made aware that her blood counts are forcing us to ask them to stop the medicines and prepare for surgery. Why didn't she get it done earlier?
[13-06-2025 17:23] CR: I spoke to the mother of the patient. She said she will update after the PA reaches home. As she is not aware of all those details.
[13-06-2025 19:48] PPM 1: He has sent what we already have.
We need all the available hemogram reports before May 2025
[13-06-2025 20:21] CR: Spoke to him.
[13-06-2025 20:29] PPM 1: Also we need to know if he was adviced surgery before this and did they refuse earlier and would they now consider getting operated because the medicines are causing side effects
[13-06-2025 20:41] CR: They have gone to a local doctor 2 yrs back and was told everything is alright and gave medication. After that they did not consult anyone and recently came to Kamineni. They are willing for surgery when I told that medicines are causing side effects.
[13-06-2025 21:04] CR: They want to know the cost for surgery and where it can be done
[13-06-2025 21:42] PPM 1: It can be done here and may not cost more than 15,000
[13-06-2025 21:44] CR: Informed them.
[14-06-2025 11:42] CR: Can it be done under Arogyasree scheme?
[14-06-2025 13:16] PPM 1: Surgery here in our hospital is free. However it's the unnecessary medicines that cost money and there could be a big nexus around that which the doctors may not be able to break @PPM2 @Meta AI
[14-06-2025 13:16] Meta AI: That's a pretty valid concern, bruh 🙄. Unnecessary prescriptions can be a major issue, especially if there's a kickback system involved 💸. You think the hospital's got some sort of deal with pharma companies or what? 🤔 Got any evidence or is this just a hunch?
[14-06-2025 13:17] PPM 1: @Meta AI not the hospital but the OT staff mafia in the entire country
[14-06-2025 13:17] Meta AI: You're talking about a much bigger issue now. If there's a widespread issue with OT staff or doctors prescribing unnecessary medicines for personal gain, that's a serious problem that needs investigation. Have you reported this to any authorities or is it just a rumor going around?
[14-06-2025 13:17] PPM 1: @Meta AI it's an untestable hypothesis since decades
[14-06-2025 13:17] Meta AI: That's a tough one. If it's been going on for decades and there's no concrete evidence, it's hard to prove or disprove. But it's definitely a concern that affects patient welfare and trust in the healthcare system. Do you think stricter regulations or oversight could help address this issue?
[14-06-2025 13:18] PPM 1: @Meta AI we are waiting for compassionate robots to take over (humankind)!
[14-06-2025 13:18] Meta AI: 😂 Compassionate robots taking over healthcare, eh? Maybe one day we'll get there! Until then, I think a mix of better regulations, transparency, and patient advocacy could help improve the system. What do you think robots would do differently, though?
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