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Medical Science Monitor Basic Research


Graves' Disease Presenting as Autoimmune Hemolytic Anemia

Unusual clinical course, Challenging differential diagnosis

Stefanus Gunawan Kandinata, Soebagijo Adi Soelistijo, Putu Niken A. Amrita

Indonesia Department of Internal Medicine, Dr. Soetomo General Academic Hospital – Faculty of Medicine Airlangga University, Surabaya, Indonesia

Am J Case Rep 2021; 22:e930705

DOI: 10.12659/AJCR.930705

Available online: 2021-03-19

Published: 2021-04-23


BACKGROUND: Atypical manifestations of Graves’ disease (GD) such as anemia have been noticed in the last decades. Anemia is present in up to 34% of patients with GD, yielding various anemia types such as GD anemia, pernicious anemia, iron deficiency anemia, and autoimmune hemolytic anemia (AIHA). So far, AIHA is the rarest manifestation of anemia in GD.
CASE REPORT: We report a case of 29-year-old woman with initial presentation of typical anemia. Further findings revealed GD signs and symptoms such as orbitopathy, increased appetite along with loss of weight, and hand tremors. Laboratory findings showed very low hemoglobin (3.9 g/dL), reticulocytosis, elevated indirect bilirubin, and positive direct Coomb’s test. Later, thyroid function testing showed decreased TSH, elevated fT4, and positive TrAb. The diagnosis of GD was made, with AIHA as initial presenting manifestation. The patient was treated using corticosteroids followed by anti-thyroid without any blood transfusion and responded well.
CONCLUSIONS: In this case, typical AIHA was the initial presenting manifestation of GD and should not be overlooked since delayed diagnosis increases morbidity and mortality. Thyroid function assessment may be needed to search for etiologies of AIHA. Regardless of the exact underlying pathophysiology, AIHA under GD generally responds well to anti-thyroid and steroid treatment.

Keywords: Anemia, Hemolytic, Autoimmune, Graves Disease, Thyroid Diseases