Marrow hypoplasia: a rare complication of untreated Grave’s disease

Abstract

SUMMARYAtypical presentation forms of hyperthyroidism are always a challenge to the clinician. We pre sent a female patient with the typical symptoms of thyrotoxicosis, without any thionamides treatment before, associated with pancytopenia, which recovered after euthyroidism state was achieved. Although the major cases of pancytopenia in Grave's disease are seen as a compli cation of antithyroid drugs (thioamides), in this case report the alteration in blood tests was associated with untreated hyperthyroidism. In the literature review, we found 19 case reports between 1981 to 2012, but it has been related to a hypercellular bone marrow with periferic destruction. Our case, however, is about a hypocellular bone marrow without fibrosis or fat tissue replacement, which proceeded with a periferic improvement following thyroid treatment. Although rare, pancytopenia, when present, may develop as an unusual and severe manifesta tion in untreated subjects. Arq Bras Endocrinol Metab. 2014;58(9):953-7 SUMÁRIOFormas atípicas de apresentação do hipertireoidismo são sempre um desafio para o clínico. Apresentamos uma paciente do sexo feminino, com sintomas típicos de tireotoxicose associa do a um quadro de pancitopenia sem nenhum tratamento prévio com tionamidas. A melhora da alteração hematológica ocorreu após recuperação do eutireoidismo. Embora a maioria dos casos de pancitopenia na doença de Graves seja uma complicação das drogas antitireoidianas (tionamidas), neste caso a alteração hematológica foi associada ao quadro de hipertireoidismo não tratado. Após uma revisão na literatura, encontramos 19 relatos de caso descritos no perío do de 1981 a 2012, nos quais o quadro de pancitopenia estava relacionado à hipercelularidade medular com destruição periférica das células sanguíneas. Nosso caso, entretanto, tratase de uma pancitopenia com medula óssea hipocelular, sem infiltração por tecido adiposo ou fibrose, que evoluiu com melhora dos elementos do sangue periférico após tratamento do hipertireoi dismo. Embora rara, a pancitopenia, quando presente, pode se manifestar como uma severa manifestação se não tratada a condição desencadeadora. Arq Bras Endocrinol Metab. 2014;58(9):953-7

Atypical Complications of Graves’ Disease: A Case Report and Literature Review

“…There was no identifiable cause for this patient's anemia and it was similar to an anemia of chronic disease, commonly called “GD anemia,” that affects 22% of patients with GD [12]. Bone marrow examination in patients with GD, although was not performed in our case, could show hypercellular [8], normocellular [1, 5, 6], or, very rarely, hypoplastic [4] changes.…”

“…It is rare for patients with GD to have pancytopenia; there are only a few documented reports in the literature [1, 4–9]. However, single lineage abnormalities (anemia, leukopenia, or thrombocytopenia) are more common in patients with hyperthyroidism (34%, 5.8%, and 3.3%, resp.)…”

“…The duration of hyperthyroidism related pancytopenia is variable, from 2 weeks [1] to several months [4]; it resolves only when the patient is euthyroid. Pancytopenia should resolve by the time euthyroidism is reestablished; if it does not, hematologic evaluation should be revisited.…”

“…The pathogenesis of GD-related pancytopenia is not fully understood and different theories exist [1, 4, 5, 10], including the following: (i) high level of circulating thyroid hormones, resulting in ineffective hematopoiesis; (ii) shortened blood cell lifespan, either by immune destruction or by sequestration; (iii) autoimmune mechanisms, given the presence of antineutrophil and antiplatelet antibodies; and (iv) direct bone marrow toxicity, as excessive thyroid hormones may adversely affect the pluripotent stem cells.…”

Graves' disease with pancytopenia and hepatic dysfunction: A rare case presentation

“…The various proposed pathogeneses are (a) direct effect of thyroid hormones on hematopoiesis, (b) reduction in blood cell lifespan caused due to autoimmunity, and (c) toxicity of thyroid hormone to bone marrow stem cells. [111213] However, in most of the cases, there is prompt improvement in blood cell counts with normalization of thyroid status, which suggests that there is some direct effect of thyroid hormones. Further, pancytopenia has also been reported with hyperthyroidism forms other than GD such as multinodular goiter[11] and even with overdosing of levothyroxine.…”