Objective : Hematological abnormalities are common in hyperthyroidism but are not usually clinically significant. Thyrotoxicosis and Graves’ disease are known to cause single lineage cytopenias with anemia being most common followed by thrombocytopenia and leukopenia. Pancytopenia is a very rare complication. We present a case of a young patient found to have pancytopenia secondary to Graves’ disease.
Methods : A 35-year-old male with no significant past medical history presented with fevers and chills following an outpatient colonoscopy. Family history was significant for colon cancer and maternal Graves' disease. On admission, his temperature was 39.7℃ with labs significant for: absolute neutrophil count (ANC) 0.47 B/L (1.5-8 B/L), hemoglobin 12 g/dL (14-17 g/dL), and platelets 70 B/L (140-400 B/L). All were normal months prior. He reported 45-pound partially-intentional weight loss. Physical exam was unremarkable. Treatment was initiated for neutropenic fever. He had extensive infectious, hematologic, and rheumatologic work up and imaging. All were normal except for thymic hyperplasia and mild splenomegaly. His bone marrow biopsy was reported as normocellular with left-shifted maturation, consistent with a reactive process. Thyroid function tests were ordered for weight loss revealing: TSH
Results : N/A
Discussion : Pancytopenia is a rare complication of Graves’ disease, the etiology of which is still unclear. It is thought to be from reduced production, increased destruction (from anti-neutrophil antibodies) and/or increased sequestration of hematopoietic cells. As in our case, patients may have mild splenomegaly and/or thymic hyperplasia which often resolve with treatment of the underlying Graves’ disease.
Conclusion : Thorough hematologic evaluation of all patients with pancytopenia and Graves' disease should be performed before administering antithyroid drugs. Reevaluation of the bone marrow must be done if peripheral blood cell counts do not recover after becoming euthyroid.
Deepika Nandiraju– Fellow in training, Thomas Jefferson University hospital, Philadelphia, Pennsylvania
Jonathan Li– MS4, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
Alan Kubey– Clinical Instructor (TJUH) and Supplemental Consultant (Mayo), respectively, Division of Hospital Medicine, Thomas Jefferson University Hospital, Philadelphia, PA and Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
Serge Jabbour– Professor of Medicine, Director - Division of Endocrinology, Thomas Jefferson University Hospital, philadelphia, Pennsylvania
Fellow in training
Thomas Jefferson University hospital
second year Fellow in training
Sidney Kimmel Medical College at Thomas Jefferson University
Jonathan C. Li, earned an undergraduate degree in biochemistry from Stony Brook University and is a fourth-year medical student at Sidney Kimmel Medical College at Thomas Jefferson University. His accomplishments during medical school include completion of the Clinical-Translational Research Track with contributions to the fields of pulmonary disease and peptide biology and induction into The Gold Humanism Honor Society. He is currently applying for residency in Combined Internal Medicine & Pediatrics.
Clinical Instructor (TJUH) and Supplemental Consultant (Mayo), respectively
Division of Hospital Medicine, Thomas Jefferson University Hospital, Philadelphia, PA and Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
Dr. Kubey is a clinically-focused hospitalist with emphasis on evidence-based medicine resident and student learning at Thomas Jefferson University Hospital in Philadelphia, PA and the Mayo Clinic in Rochester, MN. Research interests include quality and systems improvement to advance high-value care delivery, light and circadian physiology to improve clinician performance and patient outcomes, outpatient medication cost reduction to raise adherence rates, and novel patient-deterioration-prediction clinical decision support systems to reduce inpatient morbidity and mortality. Honors include winning the top prize at the 2017 national American College of Physicians innovation competition and the 2018 Thomas Jefferson University Internal Medicine Residency Program “Teacher of the Year” award.
Professor of Medicine, Director - Division of Endocrinology
Thomas Jefferson University Hospital
Jabbour is Professor of Medicine and Director of the Division of Endocrinology, Diabetes, and Metabolic Diseases in the Department of Medicine at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania. He is also Director of the Jefferson Diabetes Center.
Dr Jabbour completed his training in Endocrinology, Diabetes, and Metabolic Diseases at Thomas Jefferson University in Philadelphia.