Introduction: Graves disease is frequently associated with cytopenia. Pancytopenia, however, is rare. Thyroid hormones have a direct effect on myocardial contractility and left ventricle (LV) diastolic function. Only less than 1% of the patients with hyperthyroidism develop cardiomyopathy with impaired left ventricular systolic function.
Case: A 51-year old woman was admitted to the Hospital of Lithuanian University of Health Sciences, Kaunas clinics with 6 months history of tachycardia, bilateral leg oedema and progressive dyspnea. For 9 years, the patient was treated with Thiamasole for thyrotoxicosis. Physical examination demonstrated enlarged thyroid, pale skin, cyanotic lips. Both legs were swollen below the knee down to the feet. There was no endocrine ophthalmopathy. Cardiac auscultation revealed an irregular heartbeat with rate of 128 bpm. Laboratory tests: TSH <0.001 mIU/l (0.274.2), FT4 34.38 pmol/l (1222), FT3 7.38 pmol/l (3.345.14), anti-TSH-R 180 U/l (<9), anti-TPO 307.4 kU/l (012), anti-Tg 12 kU/l (0100). Pancytopenia was diagnosed by haemoglobin 60 g/l (135169), neutrophils 1.30×109/l (1.87.4), platelets 64×109/l (166308). An electrocardiogram showed atrial fibrillation with heart rate of 128 bpm. Thyroid ultrasonography revealed enlarged thyroid gland with bilateral hypoechogenic zones. Color Doppler showed a highly increased vascularisation. Chest X-ray showed hydrothorax (12.3 cm liquid in the right pleura). Therapeutic thoracocentesis was performed. 5.6 cm of free abdominal fluid were observed in the peritoneal cavity by abdominal US. A transthoracic echocardiogram (TTE) was performed after intensive treatment (after 1 month), when clinical symptoms regressed. TTE showed moderately reduced systolic LV function (ejection fraction 50%), normal LV diastolic function; mild pericardial effusion, moderate aortic regurgitation, expanded mitral valve ring and severe mitral regurgitation. Red blood cells were transfused to treat anaemia. Prednisolone 40 mg/d were prescribed while gradually reducing the dose. Treatment with Thiamasole was continued and the dose was increased to 30 mg/d after adjusting the amount of the leukocytes. In order to relieve the symptoms, diuretics were prescribed, B-blocker and anticoagulation therapy was also started to prevent embolisms due to atrial fibrillation. Pancytopenia were no longer observed when we reached euthyrosis and the condition of the patient significantly improved. Before patients discharge we got information about positive M. tuberculosis culture in the pleural puncture. It is likely due to immunosuppression. The patient was referred to specific treatment.
Conclusion: Pancytopenia and reversible cardiomyopathy are the rare complications of Graves disease and conventional treatment for hyperthyroidism usually reverses.
18 - 21 May 2019
European Society of Endocrinology