P-78 Life-threatening fungal infection due to long term glucocorticoid usage in amiadarone thyrotoxicosis

Abstract

Abstract Introduction Amiadorone-associated thyroiditis (AIT) has 2 subtypes. In type 1, there is usually underlying thyroid disease and thyrotoxicosis occurs due to increased hormone synthesis. In type 2, thyrotoxicosis occurs as a result of T4-T3 release due to destruction(1). Steroid use is recommended in the treatment of AIT. Steroids may cause infections by affecting both innate and acquired immunity. If the patient has other comorbidities, long-term hospitalization, type 2 diabetes mellitus or lymphopenia, these factors may also predispose to infection(2). Clinical Case V.E., age 63, male. The patient was diagnosed atrial fibrillation 4 years ago and was started on amiadorone. After 3 years of amiadorone use, amiadorone was discontinued in January 2023. In April, thyrotoxicosis was detected in an external center where he went with complaint of weight loss. The patient was considered to have amiadorone-associated thyroiditis and methyl prednisolone treatment was started. He used approximately 2 grams of steroid and methimazole 2×15 mg regularly for 2 months. During the period of steroid use, TSH value was always suppressed and T4 value was always 3-4 times the reference value. With the use of methyl prednisolone, severe myopathy developed especially in the proximal muscles and steroid induced diabetes was diagnosed. The patient was admitted to our hospital on 06.07.2023.TSH value was found to be suppressed and T4>100 pmol/liter (reference:11-22). On admission examination, there were diffuse candida plaques in the mouth. On pulmonary examination, rales were heard in the right lung and voriconazole was started because of fungal infection in the right hilar region on tomography. Steroid was discontinued and methimazole was increased to 2×30 mg in the patient who was thought to have fungal infection and had severe myopathy. Cholestyramine was added to his treatment. Voriconazole was discontinued in the patient who had visual hallucinations after 5 days of voriconazole use. During follow-up, the patient developed hypoxia 6 days later and a newly developed cavity in the lower lobe of the right lung was observed in the tomography. The findings were evaluated in favor of fungal pneumonia in the foreground and amphotericin B was started with the recommendation of infectious diseases. Galactomannan, aspergillus and Quantiferon tests were negative. The patient was consulted to pulmonology department because of the newly developed cavity and fiberoptic bronchoscopy was planned. Bronchoscopy showed no appearance suggestive of malignancy. Tuberculosis PCR was negative. T4 values and acute phase reactants completely regressed under treatment and the patient was discharged. Conclusion Steroid treatment is used in AIT type 2 and in cases of indistinguishable AIT, but it should not be ignored that this treatment has its own side effects. Especially, not giving steroids for a long time and trying to reduce the dose as soon as possible will be important in reducing steroid-related side effects.