AUTOIMMUNE HEMOLYTIC ANAEMIA

A RARE MANIFESTATION OF GRAVES’ DISEASE

Abstract

INTRODUCTION/BACKGROUND
Anemia is an atypical manifestation of Graves’ Disease (GD). Autoimmune hemolytic anaemia (AIHA) is one of the rarest anemias seen in GD.

CASE
A 55-year-old female presented with failure symptoms and palpitations, with no other hyperthyroid symptoms. She was tachycardic (130 to 140 bpm) with an irregularly irregular heart rhythm. She had pallor, jaundice, thyromegaly without bruit, fine crepitations on both lung fields and pedal edema. She had no murmur or hepatosplenomegaly. Chest radiograph showed congested lungs. Initial blood investigations showed normochromic normocytic anaemia (hemoglobin 6.7 g/dL), and normal WBC and platelet count. Hemolytic workup showed elevated indirect bilirubin (63 µmol/L), positive direct Coombs test, high reticulocyte count (10.8%), and RBC agglutination with few spherocytes on full blood picture. LDH was normal. She had elevated fT4 (58.5 pmol/L), low TSH (<0.005 m IU/L) and high levels of antithyroid peroxidase antibodies (84 IU/mL). She was not in thyroid storm. She was treated with carbimazole 30 mg OD and prednisolone 30 mg OD with respective tapering doses. She was well during our clinic review two weeks later. Hemoglobin (10.4 g/dL) and indirect bilirubin (28 µmol/L) improved without blood transfusion.

CONCLUSION
The presentations of Graves’ disease may vary. While pernicious and iron deficiency are the common causes of anemia in GD, AIHA is rare. It is crucial to screen for thyroid disease in AIHA. The scarcity of pure AIHA manifestation in GD may potentially delay the diagnosis and lead to poor patient outcomes. AIHA in GD responds well to antithyroid and steroid.