Moore Joseph A, Gliga Louise, Nagalla Srikanth
Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States.
Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States.
Transfus Apher Sci. 2017 Aug;56(4):606-608. doi: 10.1016/j.transci.2017.08.003. Epub 2017 Aug 18.
Graves' disease is often associated with other autoimmune disorders, including rare associations with autoimmune hemolytic anemia (AIHA). We describe a unique presentation of thyroid storm and warm AIHA diagnosed concurrently in a young female with hyperthyroidism. The patient presented with nausea, vomiting, diarrhea and altered mental status. Laboratory studies revealed hemoglobin 3.9g/dL, platelets 171×10L, haptoglobin <5mg/dL, reticulocytosis, and positive direct antiglobulin test (IgG, C3d, warm). Additional workup revealed serum thyroid stimulating hormone (TSH) <0.01μIU/mL and serum free-T4 (FT4) level 7.8ng/dL. Our patient was diagnosed with concurrent thyroid storm and warm AIHA. She was started on glucocorticoids to treat both warm AIHA and thyroid storm, as well as antithyroid medications, propranolol and folic acid. Due to profound anemia and hemodynamic instability, the patient was transfused two units of uncrossmatched packed red blood cells slowly and tolerated this well. She was discharged on methimazole as well as a prolonged prednisone taper, and achieved complete resolution of the thyrotoxicosis and anemia at one month. Hyperthyroidism can affect all three blood cell lineages of the hematopoietic system. Anemia can be seen in 10-20% of patients with thyrotoxicosis. Several autoimmune processes can lead to anemia in Graves' disease, including pernicious anemia, celiac disease, and warm AIHA. This case illustrates a rarely described presentation of a patient with Graves' disease presenting with concurrent thyroid storm and warm AIHA.
格雷夫斯病常与其他自身免疫性疾病相关，包括与自身免疫性溶血性贫血（AIHA）的罕见关联。我们描述了一名患有甲状腺功能亢进症的年轻女性同时被诊断出甲状腺风暴和温抗体型自身免疫性溶血性贫血的独特病例。患者出现恶心、呕吐、腹泻和精神状态改变。实验室检查显示血红蛋白3.9g/dL、血小板171×10⁹/L、触珠蛋白<5mg/dL、网织红细胞增多，直接抗球蛋白试验（IgG、C3d、温抗体型）阳性。进一步检查发现血清促甲状腺激素（TSH）<0.01μIU/mL，血清游离甲状腺素（FT4）水平7.8ng/dL。我们的患者被诊断为同时患有甲状腺风暴和温抗体型自身免疫性溶血性贫血。她开始接受糖皮质激素治疗温抗体型自身免疫性溶血性贫血和甲状腺风暴，以及抗甲状腺药物、普萘洛尔和叶酸。由于严重贫血和血流动力学不稳定，患者缓慢输注了两单位未交叉配血的浓缩红细胞，耐受性良好。她出院时服用甲巯咪唑以及逐渐减量的泼尼松，一个月时甲状腺毒症和贫血完全缓解。甲状腺功能亢进症可影响造血系统的所有三种血细胞系。甲状腺毒症患者中10% - 20%可见贫血。几种自身免疫过程可导致格雷夫斯病患者出现贫血，包括恶性贫血、乳糜泻和温抗体型自身免疫性溶血性贫血。本病例说明了格雷夫斯病患者同时出现甲状腺风暴和温抗体型自身免疫性溶血性贫血这种罕见的表现。
