Endocrine Abstracts

Introduction: Association between autoimmune thyroid disease (AITD) and other autoimmune disorders is common and known as autoimmune polyglandular syndrome (APS). It may involve hypoparathyoridism with Addison disease (AD) and mucocutaneous candidiasis – APS type I, AD with Diabetes mellitus type 1 (DM1) or AITD- APS type II, AITD associated with other autoimmune diseases (excluding AD): DM1- type IIIa, pernicious anemia- IIIb, or alopecia and/or vitiligo and/or other autoimmune disorder- IIIc, any other combination being classified as APS type IV. We report a case of a 15-year old patient diagnosed simultaneously with Graves disease (GD) and severe autoimmune thrombocytopenia (AIT).

Clinical case: A 15-year-old female patient was admitted to hospital with palpitations, weight loss, petechiae on lower limbs, during menstruation. Physical examination revealed tachycardia, goiter, thyroid bruit, fine distal tremor, petechiae of trunk, upper and lower limbs. Abnormalities in laboratory studies: thrombocytopenia-platelet count: 4.0×10³/ul, clinical hyperthyroidism with positive TSH receptor antibody. Myelogram: normal. Thyroid ultrasonography: enlarged thyroid gland, colour Doppler: increased blood flow. She was treated with intravenous immunoglobulin (IVIG), platelets concentrate and started methimazole. During follow-up she had 4 more episodes of severe thrombocytopenia, with good however temporary response to therapy with IVIG or intravenous corticosteroids. Meanwhile vitamin B12 deficiency was detected and vitamin B12 replacement therapy started. After normalization of thyroid function, maintaining low dose of methimazole, thrombocytopenia persisted (platelet count>20×10³/ul). Anty-glutamic acid decarboxylase(GAD) antibodies were tested: positive, without hyperglycemia.

Comments: Although some autoimmune diseases may coexist, combination of AIT and GD is rarely reported. Moreover it was unusual because of juvenile onset, severity of thrombocytopenia, simultaneous diagnosis of GD, concomitant presence of GAD antibodies and vitamin B12 deficiency. The patient needs to be monitored closely for early detection of other autoimmune disorders or glandular failure and initiate hormone replacement therapy if it is established.