Graves disease induced pancytopenia in a patient withthyroid storm. A case report

Author(s): Medina Jasso Juan

Introduction: Graves’ disease can affect the hematological system, manifesting itself even with pancytopenia, conditioning a therapeutic dilemma in the use of thiamazole due to its secondary hematological effects. 
Case Presentation:  We  present the case of a 55-year-old woman who came for weight loss, diarrhea,   and insomnia; 5 days before admission fever, dyspnea, and transvaginal bleeding were added.  Her  physical examination showed exophthalmos,  tachycardia,  hyperthermia,  goiter,  Means-Lerman  rub,  and lower limb ecchymosis. A Wartofsky score of 45 consistent with thyroid storm was documented. Examinations showed elevated thyroid hormones, with pancytopenia (Table 1). Other causes of pancytopenia were ruled out: the bone marrow aspirate showed lymphocytic, normocellular infiltration; ELISA for human immunodeficiency virus, VDRL (Venereal Disease Research Laboratory) test, antibodies against  cytomegalovirus,  toxoplasma,  and  rubella  was  reported   negative.   Thyroid   ultrasound showed goiter in the presence of increased generalized Doppler flow (Figure 1). After treatment with methimazole (had not previously received it), propranolol, hydrocortisone, and cholestyramine  the  patient  showed  improvement  in  hematopoietic  function  with  the  resolution  of  the  thyroid  storm. 
Conclusions: In this case, it was demonstrated in a patient with recently diagnosed Graves’ disease, without prior use of methimazole and having ruled out other etiologies of pancytopenia, that hyperthyroidism can induce hematological alterations; explained by the direct effect of hormones by causing a disorder in the maturation and differentiation of the hematopoietic stem cell, by reducing the half-life of blood cells by hypersplenism or by the presence of antineutrophil or antiplatelet antibodies. Treatment with methimazole and hydrocortisone remitted the thyroid storm  and  restored hematopoietic function, therefore, it was considered that 1) a hematologic evaluation of all patients with Graves’ disease should be performed before administering antithyroid drugs and 2) the presence of pancytopenia should not be considered a contraindication to administer methimazole.