Literature DB >> 34841067

Thyrotoxicosis due to 1000-fold error in compounded liothyronine: A case elucidated by mass spectrometry.

Wajid Khan1, Grace Van Der Gugten2, Daniel T Holmes2,3.   

Abstract

BACKGROUND: Thyrotoxicosis attributable exclusively to triiodothyronine (T3) is, by necessity, caused by accidental or intentional ingestion of pharmaceutical preparations. The clinical presentation of T3 overdose appears to differ from classic thyroid storm. CASE: A 30-year-old female patient presented serially to the emergency department with headache, nausea and vomiting. Neurological work-up was negative and she was treated for presumed viral gastroenteritis. Eventually she developed confusion and was admitted. Laboratory investigations showed a suppressed TSH and a free T3 above the linear range (>30 pmol/L), estimated by dilution in normal serum to be 330 pmol/L. She was diagnosed with thyrotoxicosis secondary to recently prescribed compounded liothyronine and was treated with seven rounds of plasmapheresis. Using a rapidly developed mass spectrometric method for T3, it was determined that compounding pharmacy had dispensed liothyronine at a concentration ≃ 1000 -times the prescribed dosage.
CONCLUSION: The clinical and mass spectrometry laboratories played an essential role in the diagnosis of thyroid storm in this case of T3 overdose as the expected clinical features of hyperpyrexia, tachycardia and hypertension were initially absent.
© 2018 The Association for Mass Spectrometry: Applications to the Clinical Lab (MSACL). Published by Elsevier B.V.

Entities:  

Keywords:  Compounding; Cytomel; Liothyronine; Mass spectrometry; Pharmacy; Thyroid storm; Thyrotoxicosis

Year:  2018        PMID: 34841067      PMCID: PMC8620522          DOI: 10.1016/j.clinms.2018.11.003

Source DB:  PubMed          Journal:  Clin Mass Spectrom        ISSN: 2213-8005


  10 in total

1.  The normal TSH reference range: what has changed in the last decade?

Authors:  Bernadette Biondi
Journal:  J Clin Endocrinol Metab       Date:  2013-09       Impact factor: 5.958

2.  Triiodothyronine intoxication.

Authors:  P A Dahlberg; F A Karlsson; L Wide
Journal:  Lancet       Date:  1979-09-29       Impact factor: 79.321

3.  Iatrogenic thyrotoxicosis and the role of therapeutic plasma exchange.

Authors:  Kabeer K Shah; Michael M Mbughuni; Edwin A Burgstaler; Darci R Block; Jeffrey L Winters
Journal:  J Clin Apher       Date:  2017-03-20       Impact factor: 2.821

4.  Toward Better-Quality Compounded Drugs - An Update from the FDA.

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Journal:  N Engl J Med       Date:  2017-12-28       Impact factor: 91.245

5.  A 1000-fold overdose of clonidine caused by a compounding error in a 5-year-old child with attention-deficit/hyperactivity disorder.

Authors:  M J Romano; A Dinh
Journal:  Pediatrics       Date:  2001-08       Impact factor: 7.124

Review 6.  Iatrogenic thyrotoxicosis: causal circumstances, pathophysiology, and principles of treatment-review of the literature.

Authors:  M Meurisse; L Gollogly; C Degauque; I Fumal; T Defechereux; E Hamoir
Journal:  World J Surg       Date:  2000-11       Impact factor: 3.352

7.  Severe accidental overdose of 4-aminopyridine due to a compounding pharmacy error.

Authors:  Eric Schwam
Journal:  J Emerg Med       Date:  2009-05-13       Impact factor: 1.484

8.  Thyroid storm due to inappropriate administration of a compounded thyroid hormone preparation successfully treated with plasmapheresis.

Authors:  Sujeet Jha; Swati Waghdhare; Rajashekar Reddi; Priyanka Bhattacharya
Journal:  Thyroid       Date:  2012-10-15       Impact factor: 6.568

9.  Deaths from intravenous colchicine resulting from a compounding pharmacy error--Oregon and Washington, 2007.

Authors: 
Journal:  MMWR Morb Mortal Wkly Rep       Date:  2007-10-12       Impact factor: 17.586

Review 10.  Potential risks of pharmacy compounding.

Authors:  Jennifer Gudeman; Michael Jozwiakowski; John Chollet; Michael Randell
Journal:  Drugs R D       Date:  2013-03
  10 in total

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