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

Abstract

Graves' disease (GD) may display uncommon manifestations. We report a patient with rare complications of GD and present a comprehensive literature review. A 35-year-old woman presented with a two-week history of dyspnea, palpitations, and edema. She had a raised jugular venous pressure, goiter, and exophthalmos. Laboratory tests showed pancytopenia, a raised alkaline phosphatase level, hyperbilirubinemia (mainly direct bilirubin), and hyperthyroidism [TSH: <0.01 mIU/L (reference values: 0.45–4.5), fT4: 54.69 pmol/L (reference values: 9.0–20.0), and fT3: >46.08 pmol/L (reference values: 2.6–5.7)]. Her thyroid uptake scan indicated GD. Echocardiography showed a high right ventricular systolic pressure: 60.16 mmHg. Lugol's iodine, propranolol, cholestyramine, and dexamethasone were initiated. Hematologic investigations uncovered no reason for the pancytopenia; therefore, carbimazole was started. Workup for hepatic impairment and pulmonary hypertension (PH) was negative. The patient became euthyroid after 3 months. Leukocyte and platelet counts and bilirubin levels normalized, and her hemoglobin and alkaline phosphatase levels and right ventricular systolic pressure (52.64 mmHg) improved. This is the first reported single case of GD with the following three rare manifestations: pancytopenia, cholestatic liver injury, and PH with right-sided heart failure. With antithyroid drugs treatment, pancytopenia should resolve with euthyroidism, but PH and liver injury may take several months to resolve.

Pancytopenia and Lymphoid Organ Hyperplasia in a Patient with Graves Disease: Response to Antithyroid Drug Therapy

“…In most cases of pancytopenia or cytopenia related to GD, treatment of GD leads to cell count recovery. Recovery time ranges from a few weeks to >1 year (1). As in our case, we observed improved blood count trends after methimazole initiation with normalization at least as early as 79 days after the patient's index discharge.…”

“…Pancytopenia is a rare complication of GD thought to be secondary to thyrotoxicosis, immune-mediated destruction, sequestration, and vitamin deficiency (1). Thyrotoxicosis is supported by the observation that pancytopenia is also seen in the setting of multinodular goiter and Hashimoto thyroiditis (1,2). As in this case, treatment of the hyperthyroidism causes resolution of pancytopenia (1,2).…”

“…Thyrotoxicosis is supported by the observation that pancytopenia is also seen in the setting of multinodular goiter and Hashimoto thyroiditis (1,2). As in this case, treatment of the hyperthyroidism causes resolution of pancytopenia (1,2). Some patients may require transfusions of red blood cells or platelets and vitamin B12 supplementation (2).…”

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

“…GD with pancytopenia has been described rarely in literature. [456789] Single-lineage abnormalities are more common in patients with hyperthyroidism. In hyperthyroidism, anemia, leukopenia, or thrombocytopenia occurs in approximately 34%, 5.8%, and 3.3% of patients, respectively.…”

“…In hyperthyroidism, anemia, leukopenia, or thrombocytopenia occurs in approximately 34%, 5.8%, and 3.3% of patients, respectively. [610] The anemia in GD is usually anemia of chronic disease. [6] Bone marrow examination usually shows hypercellularity (as in the present case) or normocellularity, but rarely hypoplastic changes.…”