An Unusual Case of Graves Disease with Methimazole Therapy Delaying Proper Diagnosis and Treatment of Systemic Lupus Erythematosus

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 429-448-Thyroid Neoplasia & Case Reports
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-446
Preethi Chakravarthy Sridhar*1, Paula Butler2 and Janice L Gilden3
1Mount Sinai Hospital, Chicago, IL, 2Mt Sinai Hosp Med Ctr, Chicago, IL, 3RFUMS/Chicago Med Schl, North Chicago, IL
Background: Graves disease and systemic lupus erythematosus (SLE), both autoimmune, overlap in presentation (non-specific  symptoms, pancytopenia, agranulocytosis, anemia and thrombocytopenia, and vasculitic rash), thus causing delay in proper diagnosis.

Clinical Case:  30 year old lady,G1P1Ab0,  presented with hyperthyroidism and a diffuse goiter. Laboratory: TSH 0.03 mIU/ml (0.34 – 5.6 mIU/ml=nl); free T4 3.51 ng/ml (0.58 – 1.64 ng/ml=nl); positive thyroglobulin and peroxidase antibodies ; WBC 7,800/mm3, 69% neutrophils, Hgb  13.2 gm/dl, platelets (plt) 310,000/mm3.  Methimazole (MMI) 30 mg was started.  Six months later, TSH =0.03 mIU/ml, free T4 0.65 ng/ml, WBC 3,800/mm3, Hgb 11.0 gm/dl, Plt 205,000/mm3. Four weeks later, there was generalized fatigue, palpitations, shortness of breath, sore throat, non-productive cough, fevers, chills, dizziness, and lower extremity non-tender, non-pruritic petechial rash [TSH 0.08 mIU/ml, free T4 1.45 ng/ml, free T3 2.69 pg/ml; WBC 1,500/mm3; 55% neutrophils (absolute  count 750/mm3),Hgb 9.7 gm/dl, Plt 40,000/mm; Bone marrow biopsy-no myeloid cell  suppression; negative HIV, hepatitis B &C , SPEP: polyclonal elevation in γ- globulin].  Prior ER visit suspected  ‘allergy’ and MMI had been stopped. The rash disappeared 3 days later : lowest WBC 1,400/mm3 71% neutrophils; Hgb  7.9 gm/dl; plt 7,000/mm3.

    Active SLE was diagnosed with anemia, neutropenia and thrombocytopenia [ANA 1:1280; positive anti-double stranded DNA =762 IU/ml (reference < 4 IU/ml) and anti-myeloperoxidase and proteinase-3; complement levels [C3= 45 mg/dl ( 88-201 mg/dl),C4= 5 mg/dl (16-47 mg/dl)]. Abdominal imaging-hepatosplenomegaly, splenic infarct. Methylprednisolone 1 gm for 3 days improved  WBC 3,400/mm3; 88% neutrophils, Hgb 8.9 gm/dl, plt 26,000/mm3. Two months later, SLE stabilized on prednisone 60 mg and hydroxychloroquine 200 mg daily. She was clinically euthyroid (TSH < 0.03 mIU/ml, free T4 1.67 ng/ml, free T3 2.44 pg/ml; radioactive iodine uptake scan-diffuse uptake of 50%).  10 mCi  I-131 was administered.  Six months after RAI, hyperthyroidism continues(TSH < 0.03 mIU/ml, free T4 2.46 ng/ml, free T3 4.1 pg/ml).

Conclusion: This case highlights the overlap in presentation of Graves disease and SLE.  An increased incidence of anti-thyroid antibody positivity and autoimmune thyroid disorders occur in SLE.  Lack of awareness of this association could prevent a delay in the diagnosis and management of both hyperthyroidism and SLE.

1. Pyne D, Lenberg DA: Autoimmune thyroid disease in systemic lupus erythematosus.  Ann Rheum Dis 2002; 1: 70-722. Boelaert et al. Coexisting Autoimmune Diseases in Autoimmune Thyroid Disease. The American Journal of Medicine (2010) 123, 183.e1-183.e9 3. Alessandro Antonelli et al. Prevalence of thyroid dysfunctions in systemic lupus erythematosus. Metabolism Clinical and Experimental 59 (2010) 896–900

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