Introduction: Thyrotoxicosis may be associated with anemia (1034% of thyrotoxic patients), leucopenia (1530%) and thrombocytopenia (25%). We present the case of a 13-year-old girl with Graves disease associated with severe pancytopenia.
Case presentation: The patient presented with menorrahgia and symptoms suggestive of an upper respiratory tract infection. On examination she was afebrile with a pulse rate of 100/min at rest. She had a small goiter with no signs of thyroid eye disease. There was no organomegaly or lymphadenopathy but the presence of petechiae and bruising was noted. She was admitted to the Pediatric Department and a blood count revealed pancytopenia (Hct 28.8%, Hb 9.7 g/dl, MCV 76.6 fl, MCH 25.4 pg, WBC 2010/μL, Neut:703/μL, PLT: 39500/μL). Serum ferritin, folate and B12 levels were normal and hemolysis screen was negative. Bone marrow aspiration showed reactive changes and granulocyte and platelet antibody screening was consistent with the diagnosis of autoimmune neutropenia and thrombocytopenia. On admission, there was subclinical hyperthyroidism [TSH: 0.07 μIU/ml, (0.345.6)] with positive anti-TPO, anti-TG as well as TRAb (TSH receptor antibodies) thyroid autoantibodies. Thyroid scintigraphy revealed increased uptake with a diffuse pattern. ACTH stimulation test was normal. During her hospital stay, her peripheral blood count worsened (Hct 23.1%, Hb 7.9 g/dl, WBC 1360/μL, Neut 136-430/μL, PLT 15000/μL); she received blood and platelet transfusions and was treated with antibiotics, glucocorticoids and i.v.immunoglobulin. Oral prednizolone was continued with gradual tapering over the subsequent three months. Five months later the patient developed overt hyperthyroidism [TSH<0.03 μIU/ml, FT4 2.27 ng/dl (0.61.37), T3 3.3 ng/ml (0.561.56)] and antithyroid treatment with methimazole was initiated. Management of the hyperthyroidism with antithyroid drugs proved challenging due to fluctuations in the neutrophil and platelet counts; therefore, thyroidectomy was recommended as a definitive therapeutic option.
Discussion: Although rare, an association of immune thrombocytopenia and neutropenia with autoimmune thyroid disease has been reported in several studies. Pancytopenia in association with Graves disease has been described in 23 cases in the literature. Hematologic values tend to normalize with recovery from thyrotoxicosis. Evaluation of thyroid function tests and thyroid antibodies should be part of the work-up of patients who present with thrombocytopenia, neutropenia or pancytopenia.
18 - 21 May 2019
European Society of Endocrinology