Graves Disease Causing Pancytopenia: Case Report
Published in Clinical Medicine Insights: Case Reports, the authors present a case of a 33-year-old man who presented a nonsevere pancytopenia in the context of a newly diagnosed Graves disease. Restoration of euthyroid state led to progressive correction of pancytopenia.

A 33-year-old man with no past medical history presented to the emergency department with bilateral leg edemas and progressive dyspnea over 1 month. He also complained of neck swelling, palpitations, hand tremor, nycturia, stomach aches, and diarrhea since childhood, testicular and penile edema, and involuntary weight loss (12 kg) over 4 months despite a good appetite.

Physical examination demonstrated a voluminous thyromegaly, with leg edema from the feet to the hips, dermatitis, and a raised jugular venous pulse. Cardiac auscultation revealed an irregular heart rate, with a cardiac murmur (5/6) at Erb’s point, radiating to the carotids. Pulmonary auscultation revealed pulmonary crackles in the lung bases. The abdomen was distended with a fluid thrill sign, but pain free. On genital examination, there was a translucid painless testicular edema. He had no exophthalmia.

Laboratory tests revealed pancytopenia with a nonregenerative anemia (hemoglobin = 97 g/L [normal range = 117-157 g/L], reticulocytes = 12 G/L [normal range = 25-75 G/L]), thrombopenia (T = 74 G/L [normal range = 150-400 G/L]), and leukopenia (L = 3.4 G/L [normal range = 4-10 G/L]) without agranulocytosis (neutrophil count = 1.7 G/L [normal range = 2-7.5 G/L]). Anemia workup revealed no vitamin B12 or folic acid deficiency, normal haptoglobin. A blood smear revealed no abnormality. The NT-proBNP was 1664 ng/L (normal range < 300 ng/L).

Thyroid function test detected abnormally high levels of thyroid hormones: l-triiodothyronine (T3) = 50 pmol/L (normal range = 3.5-6.5 pmol/L), l-thyroxine (T4) >100 pmol/L (normal range = 10-23 pmol/L), thyroid-stimulating hormone (TSH) = 0.01 (normal range = 0.5-4.70 mIU/L). Later, immunology revealed TRAK levels >30 U/L (normal range < 1.8 U/L) and antithyroperoxydase antibodies = 1508 kUI/L (normal range <35 IU/mL).

An electrocardiogram demonstrated atrial fibrillation (cardiac frequency = 135/min), and transthoracic ultrasound (US) showed cardiomegaly with no ventricular dysfunction. Cervical US revealed an enlarged thyroid gland (total volume = 22 mL [normal range = 5.7-17 mL]) with bilateral heterogeneous enlarged lobes, without any focal suspect lesion. Color Doppler showed a highly increased “inferno” type of vascularization. Thorax X-ray showed a pulmonary edema with small pleural effusions on both sides.

He was hospitalized. Treatment was started with carbimazole (15 mg, 3 times a day) with furosemide (40 mg/d) to treat global cardiac failure. Anticoagulation with rivaroxaban was also started to prevent embolisms due to atrial fibrillation. To reduce the heart beat fibrillation, metoprolol was given, with perindopril for pressure control.

With treatment, symptoms improved within 5 days: the tremor stopped and he had a normal bowel transit. Spontaneous cardioversion to a normal sinus rhythm lead to the regression of the edemas and weight loss (−6 kg). Within several days, restauration of a euthyroid function was linked to the correction of hematologic values. After discharge, the pancytopenia resolved completely and remained stable without any blood product transfusion.

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