Thrombotic Thrombocytopenic Purpura and Graves Disease

doi:10.1097/MAJ.0b013e31812e9735

The American Journal of the Medical Sciences

Volume 334, Issue 2, August 2007, Pages 133-135

https://doi.org/10.1097/MAJ.0b013e31812e9735 Get rights and content

ABSTRACT

Patients with an autoimmune disease have a propensity for development of a second autoimmune disease. We report the first instance of a patient with both idiopathic thrombotic thrombocytopenic purpura (TTP) and Graves disease. The TTP remitted with a combination of plasmapheresis and prednisone. Methimazole led to sustained remission of the hyperthyroid state within 6 weeks. Although hyperthyroidism may induce immune imbalance causing autoimmunity, it is unclear if this influenced the development of TTP in our patient and if treatment of hyperthyroidism alone could have resulted in the cure of both diseases.

Section snippets

Case Report

A 49-year-old Caucasian woman presented with a 1-week history of progressive exertional dyspnea, palpitations, headache, fever, chills, and lower extremity bruises. She reported no visual changes, confusion, weight loss, diaphoresis, and diarrhea. Physical examination revealed a systolic flow murmur, conjunctival pallor, and petechiae over her lower extremities. Ophthalmic signs of Graves disease and goiter were absent. She was afebrile.

Her laboratory evaluation was as follows: hemoglobin 7.4

Discussion

Thrombotic thrombocytopenic purpura is associated with autoimmune disorders such as autoimmune hemolytic anemia⁷ and systemic lupus erythematosus.⁸ Graves disease is frequently associated with ITP but never with TTP.⁶

The pathogenesis of Graves disease has been linked to genetic factors such as HLA-DR3 and cytotoxic T-lymphocyte antigen-4 (CTLA-4) and to environmental factors such as stress, female sex steroids, and certain infections (Yersinia enterocolitica, retroviruses).⁹ The etiology of

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Citation Excerpt :
There are few reports describing the association between Grave disease and TTP. Neurologic involvement was mild in these cases, with headache,7 confusion, and disorientation.8,9 To our knowledge, severe brain involvement by TTP in addition to Grave disease has never been reported.
Thrombotic thrombocytopenic purpura (TTP) is a hematologic disease involving the platelet aggregation and resulting in hemolytic anemia, thrombocytopenia, and microvascular occlusion. Although frequent neurologic features are headache and confusion, focal deficit is described in 30% of the cases. There are a lot of causes inducing thrombotic thrombocytopenic, but reports are lacking when associated with Grave disease. We describe the case of a 51-year-old Caucasian woman presenting a 24-hour story of sudden onset of dysarthria and left superior limb palsy. Four months before, she developed severe hyperthyroidism associated with petechiae, hemolytic anemia, thrombocytopenia, and schistocytes at blood film examination. Relapse of TTP in association with Grave disease was diagnosed. There are few reports describing association between Grave disease and TTP with only mild neurologic involvement. We described, to our knowledge, the first case of acute ischemic stroke secondary to thrombotic thrombocytopenic induced by thyrotoxicosis.
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Case ReportsThrombotic Thrombocytopenic Purpura and Graves Disease

ABSTRACT

Section snippets

Case Report

Discussion

Clin Immunol Immunopathol

Med Clin North Am

Semin Arthritis Rheum

Semin Arthritis Rheum

Autoimmunity and autoimmune diseases

Recent advances in thrombotic thrombocytopenic purpura

Hematology (Am Soc Hematol Educ Program)

Diagnosis and management of Graves’ disease

CMAJ

Case Reports
Thrombotic Thrombocytopenic Purpura and Graves Disease