key: cord-0806485-vhq2xsad
authors: Kobaly, Kristen; Mandel, Susan J; Cappola, Anne R; Kim, Caroline S
title: Letter to the Editor: “Our Response to COVID-19 as Endocrinologists and Diabetologists”
date: 2020-04-20
journal: J Clin Endocrinol Metab
DOI: 10.1210/clinem/dgaa212
sha: 4a024756716745b3e118a4e4a89bc00ab22d6262
doc_id: 806485
cord_uid: vhq2xsad

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However, the appropriate guidance of hyperthyroid patients taking thionamides who develop symptoms concerning for COVID-19 that could mimic infections due to agranulocytosis should be considered by endocrinologists during this pandemic.

Our clinical practice prior to this pandemic has been to instruct hyperthyroid patients taking thionamides to discontinue drug therapy and obtain a complete blood count with differential in the setting of fever or sore throat to exclude agranulocytosis, a practice that is in accordance with the ATA guidelines 2 . Agranulocytosis is reported in 0.1 to 0.3% of patients taking thionamides 3, 4 and is more likely to occur within the first 90 days of therapy 3 . Additional risk factors are older age and higher thionamide dose 3, 5 . This is considered a serious side effect with a fatality rate of 4% 6 .

The initial clinical characteristics reported from Wuhan suggest that fever is present in the majority (98.6%) of patients with COVID-19 and throat pain is present in 17.4%, with rates of 33.3% in patients requiring ICU-admission 7 . Lymphopenia, not neutropenia, can be seen in 70%. 7 Given the possible overlap in symptomatology, it is important to counsel patients taking thionamide therapy who develop fevers and/or pharyngitis during the COVID-19 pandemic. While agranulocytosis is a rare side effect, our opinion is that these patients should still have a CBC performed to exclude a rare but potentially life-threatening diagnosis. However, sending the patient to an outpatient laboratory in the setting of such symptoms may unknowing place health care workers at risk should the patient ultimately prove to have COVID-19. Therefore, these patients will need to be evaluated in an urgent care or emergency room setting, where the clinical concern for agranulocytosis should be discussed with the triage team prior to arrival, and the patient can be further evaluated with a CBC as well as COVID-19 testing as clinically indicated.

American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

Antithyroid drug-induced hematopoietic damage: a retrospective cohort study of agranulocytosis and pancytopenia involving 50,385 patients with Graves' disease

Severity of birth defects after propylthiouracil exposure in early pregnancy

Analysis of 754 cases of antithyroid drug-induced agranulocytosis over 30 years in Japan

Antithyroid Drug Side Effects in the Population and in Pregnancy

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan

A c c e p t e d M a n u s c r i p t