Amiodarone引發甲狀腺毒症合併Propylthiouracil引發急性肝炎－案例報告

Amiodarone-induced Thyrotoxicosis with Propylthiouracil-associated Hepatitis: A Case Report

張維倫(Wei-Lun Chang)

《內科學誌》 29卷1期 (2018/02) Pp. 54-59

https://doi.org/10.6314/JIMT.201802_29(1).07

摘要

Amiodarone為一高碘含量的抗心律不整藥物，在各個器官有許多不同的副作用，在甲狀腺方面可能造成甲狀腺毒症或甲狀腺機能低下，兩者的盛行率依各地區碘攝取量差異而有所不同。本案例為一57歲男性，因心房顫動長期服用amiodarone治療，使用amiodarone兩年後突然發生急性心臟衰竭合併肺水腫與呼吸衰竭住院。甲狀腺功能檢測結果符合甲狀腺毒症診斷，但並沒有出現凸眼、甲狀腺腫大或甲狀腺自體免疫抗體。因病患甲狀腺毒症合併嚴重心血管功能不良，合併使用高劑量propylthiouracil (PTU)與hydrocortisone治療。治療3日後出現急性肝炎，無法排除為藥物造成，因此停用PTU及hydrocortisone，並改用methimazole治療，後續追蹤肝指數逐漸下降至正常。出院後僅使用methimazole治療，但甲狀腺功能不但沒有下降還回升至住院前的水準，因此請病患再次住院給予類固醇治療，治療後甲狀腺功能逐步下降。期望藉由此案例報告，討論amiodarone引發甲狀腺毒症的臨床特徵、分型與治療，並探討甲狀腺毒症併發PTU引起之肝毒性時之治療選項。

關鍵字

甲狀腺毒症(Thyrotoxicosis) ； Amiodarone引發甲狀腺毒症(Amiodarone-induced thyrotoxicosis) ； Propylthiouracil引起之肝毒性(Propylthiouracil-associated hepatitis)

並列摘要

Amiodarone is an iodine-rich drug mainly used for arrhythmia control. Although very effective, amiodarone has many side effects. Some of the side effects involve the thyroid gland. Using amiodarone may lead to either thyrotoxicosis or hypothyroidism, depends on the patient’s iodine status and underlying thyroid disease. In patient with thyrotoxicosis, amiodarone-induced thyrotoxicosis (AIT) can be divided into two types according to pathogenesis. Type 1 AIT is iodine-induced hyperthyroidism. Type 2 AIT is amiodarone-induced destructive thyroiditis. The treatment is quite different between these 2 types and the differentiation is important. We present a case of amiodarone-induced destructive thyroiditis who received amiodarone therapy (200mg per day) for 2 years. Acute hepatitis was noted 3 days after treatment with large dose propylthiouracil (200mg Q6H) and resolved after withdrawal of propylthiouracil. The literature reviews focus on the identification of AIT, the differentiation between two types of AIT, the treatment for AIT and propylthiouracil-associated hepatitis.