This is a case of a 36 year- old- Filipino female, diagnosed with Graves’ disease who presented with fever and sore throat with an absolute neutrophil count (ANC) of 30.8/uL, 79 days after taking Methimazole.

Recognizing agranulocytosis, Methimazole was discontinued and started on granulocyte colony stimulating factor (GCSF), broad spectrum antibiotics, lithium, beta blocker and corticosteroids. Beta blocker and corticosteroids were given to control symptoms of thyrotoxicosis and to block peripheral conversion of T4 to T3. Therapeutic plasma exchange (TPE) was considered an option to decrease circulating thyroid hormones but is locally unavailable. The nearest hospital capable of doing therapeutic plasma exchange is in the nearby big city but the hematologist capable of performing was out of the country at that time. Hence, lithium was started to block thyroid hormones synthesis and release. However, patient complained of headache three days after giving lithium with no other symptoms of toxicity noted. Lithium assay was normal and lithium toxicity was ruled out. Patient was referred to a neurologist for dose adjustment of lithium. There was a concern on long term use of lithium because of the previous initial reaction, thus the team opted to do definitive management to control thyrotoxicosis prior to discharge after resolution of agranulocytosis. Radioactive iodine (RAI) was an option but was unavailable because of logistic reasons during that time, opting for thyroidectomy. Lugol’s solution was given for 5 days pre- operatively to decrease thyroid gland vascularity. Patient was in a euthyroid state pre-operatively.

On first post operative day, patient complained of mild paresthesia, no bleeding and no chvostek and trousseau sign, ionized calcium was requested, 0.93 (nv 1.12-1.32 mmol/L). She was given with calcium gluconate intravenous bolus followed by calcium gluconate drip for 10 hours along with calcium carbonate + Vitamin D3 600 mg/400 IU 2 tablets after lunch and after dinner.Patient was discharged after fifth postoperative day with latest absolute neutrophil count (ANC) of 1578/uL, and ionized calcium of 1.13mmol/L, clinically stable.

Favorable outcomes of patients with methimazole-induced agranulocytosis despite the resource limited setting is a result of early recognition, prompt drug discontinuation and definitive management.