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Shale WT, Umer KM, Tola GG, Guluju FA. Asymptomatic Propylthiouracil Induced Agranulocytosis in a Patient with Toxic Nodular Goiter: A Rare Case Report. Int Med Case Rep J 2023; 16:503-512. [PMID: 37701536 PMCID: PMC10493100 DOI: 10.2147/imcrj.s424053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
Background Agranulocytosis is a rare but fatal side effect of antithyroid drugs (ATDs) with incidence reported at 0.1%-1%. Agranulocytosis is defined as a granulocyte count <500 cells/μL following the use of ATDs and is an absolute contraindication to the use of these drugs; in this case, radioactive iodine (RAI) or surgery are therapeutic options. Case Presentation A 28-year-old female patient was on follow-up at our clinic after she presented with anterior neck swelling of 4 years. The patient was started on propylthiouracil (PTU) and propranolol based on clinical symptoms of hyperthyroidism and low thyroid stimulating hormone (TSH) levels. After taking the ATDs for 7 months, she came to the clinic for her regular follow-up. At this point, she was declared euthyroid and booked for surgery. Investigations were sent and the complete blood count (CBC) result showed leucopenia with agranulocytosis, even though she was completely asymptomatic. The offending ATD was immediately discontinued. The patient was kept inpatient for monitoring, and lugol's iodine and propranolol were initiated. Eight days after discontinuing the ATD, the CBC profile was determined once again, showing normalized total leukocyte, as well as, absolute neutrophil count. Eventually, the multinodular goiter (MNG) was managed with subtotal thyroidectomy. Conclusion Despite the fact that agranulocytosis is an extremely rare side effect of ATDs, most often PTU; it is a potentially fatal complication when it occurs. Patient education at the time of prescription should not be overlooked, and systematic programs should be put in place. The baseline granulocyte count should be determined and monitored on a regular basis.
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Affiliation(s)
- Wongel Tena Shale
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Keno Mohammed Umer
- Department of General Surgery, Dire Dawa University, Dire Dawa, Ethiopia
| | - Gutu Ganati Tola
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Fayera Abetu Guluju
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
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Cheng Y, Xia XY, Zhang W, Ren L, Tian CF, Liu D, Xue G. Clinical characteristics of antithyroid drug-induced aplastic anemia cases over the past 30 years. Front Endocrinol (Lausanne) 2023; 14:1064723. [PMID: 36777352 PMCID: PMC9911543 DOI: 10.3389/fendo.2023.1064723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 01/04/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE The authors aimed to investigate the clinical characteristics of antithyroid drug-induced aplastic anemia cases over the past 30 years. METHODS The data of patients with antithyroid drug-induced aplastic anemia were retrieved from PubMed and Wanfang Medical Network databases from 1992 to August 2022. The clinical characteristics, such as age distribution, gender tendency, common symptoms, blood cell count, bone marrow features, treatment strategy, and prognosis, were analyzed. RESULTS A total of 17 cases (male:female = 1:16) had been retrieved. Patients' age ranged from 16 to 74 years (median 50 years). Among them, 82.3% (14/17) of the patients were administered methimazole (MMI), and 78.6% of them had MMI ≥30 mg/day. In addition, 88.2% (15/17) of the patients had sore throat and fever, and 47.1% (8/17) of the patients had hemorrhagic symptoms. Aplastic anemia occurred within 6 months after initiation of the antithyroid therapy in 94.1% of the patients. Agranulocytosis (94.1%) was the most common and earliest blood cell change, and 47.1% of the patients experienced progressive platelet decline during the treatment process. The treatments include timely withdrawal of antithyroid drugs, broad-spectrum antibiotics, granulocyte colony-stimulating factor (G-CSF)/granulocyte-macrophage colony-stimulating factor (GM-CSF), glucocorticoids and other immunosuppressive agents, and supportive treatments such as erythrocyte transfusion and platelet transfusion. Moreover, 70.6% of the patients had complete or near-complete remission within 8 days to 6 weeks. CONCLUSION Aplastic anemia is a rare and serious adverse reaction of antithyroid drugs, which is more common in women. It usually occurs during early treatment with high-dose antithyroid drugs. Most patients have a good prognosis after timely drug ceasing and appropriate treatment.
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Affiliation(s)
- Ying Cheng
- Department of Endocrinology, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
| | - Xin-Yu Xia
- Department of Endocrinology, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Wei Zhang
- Department of Endocrinology, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
| | - Li Ren
- Department of Endocrinology, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
| | - Chen-Fu Tian
- Department of Endocrinology, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
| | - Dan Liu
- Department of Endocrinology, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
| | - Gang Xue
- Department of Thyroid and Breast Surgery, The General Hospital of Western Theater Command Chinese People's Liberation Army, Chengdu, Sichuan, China
- *Correspondence: Gang Xue,
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Kim H, Lee J, Ha J. A case of antithyroid drug-induced agranulocytosis from a second antithyroid drugs (ATD) administration in a relapsed Graves' disease patient who was tolerant to the first ATD treatment. Clin Case Rep 2018; 6:1701-1703. [PMID: 30214745 PMCID: PMC6132132 DOI: 10.1002/ccr3.1644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/04/2018] [Accepted: 05/27/2018] [Indexed: 11/26/2022] Open
Abstract
Agranulocytosis is a rare side effect of antithyroid drugs (ATD) that usually develops within the first 3-6 months after starting treatment. We present a 64-year-old patient who developed agranulocytosis after starting ATD to treat relapsed Graves' disease. This patient had tolerated the first course of ATD for 72 months. This was an unusual case in which a serious side effect developed during a second ATD course. It is essential that clinicians remain vigilant to the fact that antithyroid drugs can induce agranulocytosis several years after initiated.
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Affiliation(s)
- Hyunsam Kim
- Division of Endocrinology and MetabolismDepartment of Internal MedicineCollege of MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
| | - Jeongmin Lee
- Division of Endocrinology and MetabolismDepartment of Internal MedicineCollege of MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
| | - Jeonghoon Ha
- Division of Endocrinology and MetabolismDepartment of Internal MedicineCollege of MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
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Paketçi A, Demir K, Tüfekçi Ö, Acar S, Abacı A, Yılmaz Ş, Böber E. Graves' disease following allogenic hematopoietic stem cell transplantation for severe aplastic anemia: case report and literature review. J Pediatr Endocrinol Metab 2018; 31:589-593. [PMID: 29708883 DOI: 10.1515/jpem-2017-0358] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/29/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Similar autoimmune processes (defective T-cell function) take place during the pathogenesis of aplastic anemia (AA) and Graves' disease (GD). Antithyroid drugs used for the management of GD may induce AA and GD may occur following treatment of severe aplastic anemia (SAA). CASE PRESENTATION Clinical and laboratory investigations were performed for an 11-year-and-2-month-old girl who was referred for bilateral exophthalmus and abnormal thyroid function tests. She had been diagnosed as having severe acquired AA at the age of 8 years and had been treated with allogenic hematopoietic stem cell transplantation from her healthy human leukocyte antigen-matched sibling donor. Clinical examination revealed a weight of 32.6 kg (-0.88 standard deviation [SD] score); height, 145.7 cm (-0.14 SD score); body mass index 15.5 kg/m2 (-1.01 SD score); heart rate, 110/min; blood pressure, 128/74 mmHg; bilateral exophthalmos and an enlarged thyroid gland. The laboratory workup showed hemoglobin of 11.1 g/dL; white blood cells, 7500/mL; platelets, 172,000/mL; free thyroxine (FT4), 4.80 ng/dL (normal, 0.5-1.51); free triiodothyronine (FT3), 17.7 pg/mL (normal, 2.5-3.9); thyrotropin (TSH), 0.015 mIU/mL (normal, 0.38-5.3); antithyroglobulin peroxidase (TPO) antibody, 61.7 IU/mL (normal, 0-9); antithyroglobulin (TG) antibody, <0.9 IU/mL (normal, 0-4) and thyrotropin (TSH) receptor antibodies 14 U/L (normal, 0-1). Doppler ultrasonography showed diffuse enlargement of the thyroid gland and increased vascularity. She was treated with methimazole (0.6 mg/kg/day). L-thyroxine treatment was also needed (50 μg/day). Thrombocytopenia developed during follow-up. A thyroidectomy was performed for definitive treatment at the 14th month of treatment. CONCLUSIONS The association of hyperthyroidism and AA in the pediatric age group is rare. The long-term use of antithyroid drugs and radioactive iodine should be avoided due to their hematologic toxic side effects.
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Affiliation(s)
- Ahu Paketçi
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Korcan Demir
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Özlem Tüfekçi
- Department of Pediatric Hematology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Sezer Acar
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Ayhan Abacı
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Şebnem Yılmaz
- Department of Pediatric Hematology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Ece Böber
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
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Moon Y, Jang WR, Yi HG, Park IS, Nahm CH, Choi JW, Kim JJ, Han SB. Klebsiella pneumoniae associated extreme plasmacytosis. Infect Chemother 2014; 45:435-40. [PMID: 24475358 PMCID: PMC3902819 DOI: 10.3947/ic.2013.45.4.435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 10/26/2013] [Accepted: 10/27/2013] [Indexed: 11/24/2022] Open
Abstract
Infection-associated plasmacytosis is not uncommon; however, marked plasmacytosis in both peripheral blood and bone marrow that mimicks plasma cell leukemia is a very rare condition. We encountered a case of extreme plasmacytosis associated with Klebsiella pneumoniae sepsis in an aplastic anemia patient. A 42-year-old man presented with high fever of 5 days' duration. Hematological analysis revealed severe neutropenia and thrombocytopenia; his white blood cell count was 900/mm3, with 26% of plasma and plasmacytoid cells in peripheral blood. Bone marrow biopsy and aspiration showed 25% cellularity with marked plasmacytosis (80%), highly suggestive of plasma cell leukemia. On the eighth hospital day, K. pneumoniae was identified in blood and sputum cultures. Fever improved after switching antibiotics, although his hematological condition worsened. His bone marrow cellularity (plasma cell proportion) progressively decreased: the values were 25% (80%), 10% (26%), 10% (11%), and < 10% (< 4%) on the 8th, 30th, 60th, and 90th hospital day, respectively. His plasmacytosis was extremely severe but was confirmed to be reactive with polyclonality. The present case represents the first report of strong suspicion of K. pneumoniae sepsis-associated marked plasmacytosis in an aplastic anemia patient.
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Affiliation(s)
- Yeonsook Moon
- Department of Laboratory Medicine, Inha University School of Medicine, Incheon, Korea
| | - Woo Ri Jang
- Department of Laboratory Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hyeon Gyu Yi
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - In Seo Park
- Department of Pathology, Inha University School of Medicine, Incheon, Korea
| | - Chung Hyun Nahm
- Department of Laboratory Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jong Weon Choi
- Department of Laboratory Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jin Ju Kim
- Department of Laboratory Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seung Baik Han
- Department of Emergency Medicine, Inha University School of Medicine, Incheon, Korea
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Josol CV, Buenaluz-Sedurante M, Sandoval MA, Castillo G. Successful treatment of methimazole-induced severe aplastic anaemia in a diabetic patient with other co-morbidities. BMJ Case Rep 2010; 2010:bcr0520102993. [PMID: 22802368 PMCID: PMC3029437 DOI: 10.1136/bcr.05.2010.2993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 55-year-old Filipina with Grave's disease, diabetes, hypertension, bronchial asthma, Parkinson's disease and a history of adverse drug reaction to penicillin consulted due to high-grade fever and sore throat. Patient was diagnosed with aplastic anaemia secondary to methimazole and was treated with high-dose granulocyte colony stimulating factor, thrombopoietin and mesterolone. Antibiotics used included levofloxacin, clindamycin, amikacin and fluconazole. Due to bleeding and slow recovery of blood parameters, 30 units of platelets and 7 units of packed red blood cells were transfused during her 22-day admission. This case presents a life-threatening adverse drug reaction in a patient with co-morbid conditions that complicate recovery and limit one's therapeutic options.
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Affiliation(s)
- Cindy V Josol
- Medicine Department, University of the Philippines Philippine General Hospital, Manila, Philippines.
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Abstract
BACKGROUND Antithyroid drugs have been used for more than 50 years for the management of hyperthyroidism. Most patients tolerate treatment well but some may develop life threatening side effects such as agranulocytosis and aplastic anemia (AA). We review all cases of antithyroid drug induced AA and describe, as illustrative cases, two women with Graves' disease who developed AA after 8 and 24 weeks of carbimazole (CBM) and methimazole (MMI) treatment respectively. PATIENT FINDINGS AND SUMMARY To date, at least 34 cases of aplastic anemia (AA) due to antithyroid drugs [(1 with CMZ, 31 with MMI, and 2 with propylthiouracil (PTU)] have been published, not including the two patients described here. In addition, at least another 14 patients in whom AA developed after treatment with antithyroid drugs (11 with CMZ, and 3 with MMI) have been reported in Yellow Card Scheme data analysis. Patients with AA usually exhibit sudden onset of symptoms after a relative short time of exposure to the drugs, and all have concomitant agranulocytosis. Most have a rapid recovery following discontinuation of the drug and supportive treatment. Although only two antithyroid drug induced AA deaths have been published, the mortality rate was higher in the Yellow Card Scheme data analysis. CONCLUSIONS Aplastic anemia associated with antithyroid drug treatment is rarer than antithyroid drug associated agranulocytosis. The prognosis of patients with antithyroid drug induced AA is good overall, but may not be as favorable as that of antithyroid drug induced isolated agranulocytosis.
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Affiliation(s)
- Dimitrios Thomas
- Department of Pathophysiology, Endocrine Unit, National University of Athens, Athens, Greece.
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Oh EJ, Chae HJ, Park YJ, Park JW, Han K. Agranulocytosis, plasmacytosis, and thrombocytosis due to methimazole-induced bone marrow toxicity. Am J Hematol 2007; 82:500. [PMID: 17266051 DOI: 10.1002/ajh.20879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Erve JC. Chemical toxicology: reactive intermediates and their role in pharmacology and toxicology. Expert Opin Drug Metab Toxicol 2007; 2:923-46. [PMID: 17125409 DOI: 10.1517/17425255.2.6.923] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Reactive intermediates formed during the metabolism of drugs have been investigated extensively over the past decades. Today, interest in reactive intermediates in drug discovery is focused on minimising bioactivation in hopes of reducing the risk of causing so-called idiosyncratic toxicity. These efforts are justified based on the 'hapten hypothesis', namely, that on binding to protein, reactive intermediates may elicit an immune response to the modified protein, leading to a cascade of events that ultimately manifests as a toxic outcome. However, the pharmacological action of certain drugs depends on reactive intermediates that modify critical amino acid residues of proteins, typically enzymes, thereby altering their activity. Thus, the notion that reactive intermediates are inherently dangerous is unjustified. When a reactive intermediate is necessary for the desired pharmacological effect of a drug, the selectivity it displays towards the target protein is crucial, as off-target binding may produce unwanted toxicities. On the other hand, reactive intermediates may play no role in toxicity. This review provides a balanced perspective, primarily focusing on the proposed role of reactive intermediates in drug toxicity, while also highlighting examples in which they are involved in causing the desired pharmacology. It is hoped that this knowledge can help scientists involved in drug discovery and development in their challenging task of producing safe and effective drugs.
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Affiliation(s)
- John Cl Erve
- Wyeth Research, Drug Safety and Metabolism, Collegeville, PA 19426, USA.
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Yamamoto A, Katayama Y, Tomiyama K, Hosoai H, Hirata F, Kimura F, Fujita K, Yasuda H. Methimazole-induced aplastic anemia caused by hypocellular bone marrow with plasmacytosis. Thyroid 2004; 14:231-5. [PMID: 15072706 DOI: 10.1089/105072504773297911] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Aplastic anemia is a rare but severe complication of methimazole (MMI) treatment for Graves' disease. We present a case of a 53-year-old Japanese female who had been treated with 30 mg/d of MMI for 30 days for Graves' disease and was subsequently admitted to the Japan Self Defense Forces (JSDF) Central Hospital with a mild sore throat and high-grade fever that began the previous day. The patient had a reduced white blood cell count (WBC) count of 0.9 x 10(3) per microliter with severe granulocytopenia and increased lymphocytes, a platelet count of 49 x 10(3) per microliter, and hemoglobin of 10.6 g/dL. Bone marrow (BM) aspirates showed hypocellular bone marrow with plasmacytosis. Because of poor recovery of her peripheral blood values after withdrawal of MMI, she was given transfusions of platelets and erythrocytes thereafter. This is the second report of plasmacytosis in bone marrow of MMI-induced aplastic anemia, and suggests that immunogenic mechanisms may cause this rare complication.
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Affiliation(s)
- Akemi Yamamoto
- Internal Medicine, The Japan Self-Defense Forces Central Hospital, Tokyo, Japan.
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Abstract
Some compounds having thionamide structure inhibit thyroid functions. Such antithyroid thionamides include mercaptomethylimidazole (methimazole), thiourea and propylthiouracil, of which mercaptomethylimidazole is widely used to treat hyperthyroidism. Undesirable side effects develop from these drugs due to extrathyroidal actions. Antithyroid thionamides inhibit lactoperoxidase which contributes to the antibacterial activities of a number of mammalian exocrine gland secretions that protect a variety of mucosal surfaces. These drugs stimulate both gastric acid and pepsinogen secretions, thereby augmenting the severity of gastric ulcers and preventing wound healing. Increased gastric acid secretion is partially due to the H2 receptor activation, and also through the stimulation of the parietal cell by intracellular generation of H2O2 following inactivation of the gastric peroxidase-catalase system. Severe abnormalities may develop in blood cells and the immune system after thionamide therapy. It causes agranulocytosis, aplastic anemia, and purpura along with immune suppression. Olfactory and auditory systems are also affected by these drugs. Thionamide affects the sense of smell and taste and also causes loss of hearing. It binds to the Bowman's glands in the olfactory mucosa and causes extensive lesion in the olfactory mucosa. Thionamides also affect gene expression and modulate the functions of some cell types. A brief account of the chemistry and metabolism of antithyroid thionamides, along with their biological actions are presented.
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Affiliation(s)
- Uday Bandyopadhyay
- Department of Physiology, Indian Institute of Chemical Biology, 4 Raja S.C. Mullick Road, Jadavpur, Calcutta 700 032, India
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Current literature in. Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:79-94. [PMID: 11998557 DOI: 10.1002/pds.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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