Endocrine Abstracts

Background: Graves’ disease is an autoimmune disease that is characterized by production of excess thyroid hormones by thyroid gland, which is called hyperthyroidism. Generally, clinical presentations of Graves’ disease range from asymptomatic disease to overt symptomatic hyperthyroidism with heat intolerance, tremor, palpitation, weight loss, and increased appetite. Single-cell lineage haematological abnormalities, such as anemia, leukopenia, and thrombocytopenia, although uncommon, could be part of the clinical manifestations in patients with Graves’ disease. Another rare clinical manifestation of hyperthyroidism may occur in the gastrointestinal system, including liver function tests, particularly high serum alkaline phosphatase concentrations. Thyrotoxic patients also may have numbness and weakness in lower limbs.

Case presentation: A 37-year-old male patient admitted to our clinic with palpitation, tremor, abdominal pain, nausea, vomiting, weight loss and dysphagia. Also, he had numbness and weakness in lower limbs. He was afebrile, had tachycardia (110 beats/min), and had a normal blood pressure of 116/65 mm Hg. He had a fine tremor and palpable goitre on physical examination. There were no signs of ophthalmopathy or pretibial myxedema. Laboratory investigations revealed suppressed thyrotrophin (< 0.008 mu/l) and elevated free thyroxine (6.75 ng/dl), mild thrombocytopenia (131 × 10⁹), normal serum electrolytes except mild hypokalemia (3.4 meq/l). The alkaline phosphatase and the gamma glutamyl transferase levels were elevated approximately 3–4 times the upper limit of normal with high bilirubin levels while aspartate aminotransferase and alanin aminotransferase were normal. Thyroid ultrasonography revealed chronic thyroiditis compatible with Graves disease. Thyroid receptor antibody was positive. Other causes of liver dysfunction and thrombocytopenia were ruled out. The patient was started on methimazole 20 mg/day and propranolol 40 mg/day. Complaints of the patient regressed with the improvement of cholestatic enzymes and thrombocytopenia.

Conclusion: Rare clinical manifestations of Graves’ disease such as thrombocytopenia, liver dysfunction, muscle weakness in the lower extremities, and mild hypokalemia were present in this patient. All of these findings improved with anti-thyroid therapy.