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Variable Presentation of Thrombocytopenia in Graves' Disease

Variable Presentation of Thrombocytopenia in Graves' Disease Abstract • An association between thrombocytopenia and thyrotoxicosis has been reported but its mechanism is unclear. We describe five patients in whom thrombocytopenia accompanied Graves' disease. The thrombocytopenia resembled idiopathic thrombocytopenic purpura and responded to prednisone therapy in cases 1 and 2. In case 3, thrombocytopenia remitted with treatment of the thyrotoxicosis, while, in case 4, remission occurred despite persistent hyperthyroidism. In case 5, thrombocytopenia persisted despite correction of the hyperthyroidism but remained clinically insignificant. We conclude that there is a clear association between the two conditions but the clinical patterns of presentation and pathogenesis seem heterogenous. This variability must be considered during management. (Arch Intern Med 1982;142:1460-1464) References 1. Jackson AS: Acute hemorrhagic purpura associated with exophthalmic goiter. JAMA 1931;96:38-39.Crossref 2. Toland CG, Askey JM: Atypical hemorrhagic purpura occurring with toxic adenoma of the thyroid gland. Mayo Clin Proc 1931;6:597-598. 3. Woodruff P: The behaviour of the blood platelets in thyrotoxicosis. Med J Aust 1940;2:190-197. 4. Evans H, Perry KMA: Thrombocytopenic purpura. Lancet 1943;2:410-413.Crossref 5. Conklin SD, Shank PJ: Thrombocytopenic purpura associated with exophthalmic goiter. Ohio State Med J 1944;40:47-48. 6. Roberts GF: Thrombocytopenic purpura with thyrotoxicosis. Lancet 1948;1:65-66. 7. Caldwell WGD, Meikle M: Thyrotoxicosis complicated by thrombocytopenic purpura. Br Med J 1953;2:976-977.Crossref 8. Girsh LS, Myerson RM: Thyrotoxicosis associated with thrombocytopenia and hypersplenism. Am J Clin Pathol 1957;27:328-331. 9. Zaidi ZH: Congenital thyrotoxicosis with hepatosplenomegaly and thrombocytopenia, associated with aniridia and dislocated lenses. Proc R Soc Med 1965;58:390-391. 10. Marshall JS, Weisberger AS, Levy RP, et al: Coexistent idiopathic thrombocytopenic purpura and hyperthyroidism. Ann Intern Med 1967; 67:411-414.Crossref 11. Gonzalez T: Thrombocytopenic purpura and hyperthyroidism. Ann Intern Med 1967;67:1350-1351.Crossref 12. Cattan D, Caen J, Fernandez Y, et al: Purpura thrombopenique chronique: Hyperthyroidie myxoedeme pretibial et L.A.T.S. Presse Med 1970;78:1535-1540. 13. Lamberg BA, Kivikangas V, Pelkonen R, et al: Thrombocytopenia and decreased life-span of thrombocytes in hyperthyroidism. Ann Clin Res 1971;3:98-102. 14. Takeda R, Funazu T, Odake K, et al: Idiopathic thrombocytopenic purpura associated with hyperthyroidism. South Med J 1973;66:553-556.Crossref 15. Dunlap DB, McFarland KF, Lutcher CL: Graves' disease and idiopathic thrombocytopenic purpura. Am J Med Sci 1974;268:107-111.Crossref 16. Vannasaeng D, Wasi P, Tandhanand S: Hyperthyroidism in association with idiopathic thrombocytopenic purpura. J Med Assoc Thai 1975; 58:97-105. 17. Dove AF, Petterson KG, Aronstam A: Idiopathic thrombocytopenic purpura and autoimmune thyroid disease. Practitioner 1977;218:550-552. 18. Getaz EP, Staples WG: Idiopathic thrombocytopenic purpura and hyperthyroidism. S Afr Med J 1977;52:284-285. 19. Herman J, Resnitzky P, Fine A: Association between thyrotoxicosis and thrombocytopenia. Isr J Med Sci 1978;14:469-475. 20. Resnitzky P, Schonfeld S, Dassa H: Effect of Graves' disease on idiopathic thrombocytopenic purpura. Arch Intern Med 1979;139:483-484.Crossref 21. Branehog I, Olson KS, Weingeld A, et al: Association of hyperthyroidism with idiopathic thrombocytopenic purpura and hemolytic anemia. Acta Med Scand 1979;205:125-131.Crossref 22. Axelrod AR, Berman L: The bone marrow in hyperthyroidism and hypothyroidism. Blood 1951;6:436-453. 23. Kurata Y, Nishioeda Y, Tsubakio T, et al: Thrombocytopenia in Graves' disease: Effect of T, on platelet kinetics. Acta Haematol 1980;63:185-190.Crossref 24. Hymes K, Blum M, Lackner H, et al: Easy bruising, thrombocytopenia, and elevated platelet immunoglobulin G in Graves' disease and Hashimoto's thyroiditis. Ann Intern Med 1981;94:27-30.Crossref 25. Schmidt GM, Bross KJ, Blume KG, et al: Detection of platelet-directed immunoglobulin G in sera using the peroxidase-anti-peroxidase (PAP) slide technique. Blood 1980;55:299-303. 26. Levy M, Cooper BA: Thrombocytopenic purpura associated with tuberculous lymphadenitis. Can Med Assoc J 1964;90:373-374. 27. Mueller-Eckhardt C: Idiopathic thrombocytopenic purpura (ITP): Clinical and immunologic considerations. Semin Thromb Hemostas 1977; 3:125-159. 28. Harrington WJ, Minnich V, Hollingworth JW, et al: Demonstration of a thrombocytopenic factor in the blood of patients with thrombocytopenic purpura. J Lab Clin Med 1951;38:1-10. 29. Shulman NR, Marder V, Weinrach R: Similarities between known antiplatelet antibodies and the factor responsible for thrombocytopenia in idiopathic purpura: Physiologic, serologic and isotopic studies. Ann NY Acad Sci 1965;124:499-542.Crossref 30. Steffen C: Untersuchungen uber die Verwendung der Antihumanglobin Ablenkungsmethode suz Nachweis von thrombozytenantikorpern. Wien Z Innere Med 1955;36:246-253. 31. Nelken D, Gurevitch J, Gilboa-Barber N: Direct antiglobulin consumption test for detection of immune antibodies. Lancet 1961;1:742-744.Crossref 32. Sandler RM, Voak D, Darnborough J: A simple method for detecting complement-fixation by autologous platelets in autoimmune thrombocytopenic purpura. Clin Lab Haematol 1981;3:61-70. 33. Van de Wiel TWM, van de wiel-Dorfmeyer H, van Loghem JJ: Studies on platelet antibodies in man. Vox Sang 1961;6:641-668.Crossref 34. Van Boxtel CJ, Oosterhof F, Engelfriet CP: Immunofluorescence microphotometry for the detection of platelet antibodies: III. Demonstration of autoantibodies against platelets. Scand J Immunol 1975;4:657-672.Crossref 35. Mueller-Eckhardt C, Mahn L, Schulz G, et al: Detection of platelet autoantibodies by a radioactive-anti-immunoglobulin test. Vox Sang 1978; 35:357-365.Crossref 36. Thompson P, Strum D, Boehm T, et al: Abnormalities of liver function tests in thyrotoxicosis. Milit Med 1978;143:548-551. 37. Weitzman SA, Stossel TP, Ridgway EC, et al: Antibodies to neutrophil thyrotropin (TSH) receptors in Graves' disease, abstracted. Clin Res 1980;28:498. 38. Segal BM, Weintraub MI: Hashimoto's thyroiditis, myasthenia gravis, idiopathic thrombocytopenic purpura. Ann Intern Med 1976;85:761-763.Crossref 39. Crabtree GR, Lee JC, Cornwell GG III: Autoimmune thrombocytopenic purpura and Hashimoto's thyroiditis. Ann Intern Med 1977;83:371-372.Crossref 40. Pinals RS, Tomar RH, Haas DC, et al: Graves' disease, myasthenia gravis, and purpura. Ann Intern Med 1977;87:250.Crossref 41. Wilson WA, Sissons JGP, Morgan OS: Multiple autoimmune disease with bilateral optic atrophy and lipodystrophy. Ann Intern Med 1978;89:72-73.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Variable Presentation of Thrombocytopenia in Graves' Disease

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Publisher
American Medical Association
Copyright
Copyright © 1982 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1982.00340210052013
Publisher site
See Article on Publisher Site

Abstract

Abstract • An association between thrombocytopenia and thyrotoxicosis has been reported but its mechanism is unclear. We describe five patients in whom thrombocytopenia accompanied Graves' disease. The thrombocytopenia resembled idiopathic thrombocytopenic purpura and responded to prednisone therapy in cases 1 and 2. In case 3, thrombocytopenia remitted with treatment of the thyrotoxicosis, while, in case 4, remission occurred despite persistent hyperthyroidism. In case 5, thrombocytopenia persisted despite correction of the hyperthyroidism but remained clinically insignificant. We conclude that there is a clear association between the two conditions but the clinical patterns of presentation and pathogenesis seem heterogenous. This variability must be considered during management. (Arch Intern Med 1982;142:1460-1464) References 1. Jackson AS: Acute hemorrhagic purpura associated with exophthalmic goiter. JAMA 1931;96:38-39.Crossref 2. Toland CG, Askey JM: Atypical hemorrhagic purpura occurring with toxic adenoma of the thyroid gland. Mayo Clin Proc 1931;6:597-598. 3. Woodruff P: The behaviour of the blood platelets in thyrotoxicosis. Med J Aust 1940;2:190-197. 4. Evans H, Perry KMA: Thrombocytopenic purpura. Lancet 1943;2:410-413.Crossref 5. Conklin SD, Shank PJ: Thrombocytopenic purpura associated with exophthalmic goiter. Ohio State Med J 1944;40:47-48. 6. Roberts GF: Thrombocytopenic purpura with thyrotoxicosis. Lancet 1948;1:65-66. 7. Caldwell WGD, Meikle M: Thyrotoxicosis complicated by thrombocytopenic purpura. Br Med J 1953;2:976-977.Crossref 8. Girsh LS, Myerson RM: Thyrotoxicosis associated with thrombocytopenia and hypersplenism. Am J Clin Pathol 1957;27:328-331. 9. Zaidi ZH: Congenital thyrotoxicosis with hepatosplenomegaly and thrombocytopenia, associated with aniridia and dislocated lenses. Proc R Soc Med 1965;58:390-391. 10. Marshall JS, Weisberger AS, Levy RP, et al: Coexistent idiopathic thrombocytopenic purpura and hyperthyroidism. Ann Intern Med 1967; 67:411-414.Crossref 11. Gonzalez T: Thrombocytopenic purpura and hyperthyroidism. Ann Intern Med 1967;67:1350-1351.Crossref 12. Cattan D, Caen J, Fernandez Y, et al: Purpura thrombopenique chronique: Hyperthyroidie myxoedeme pretibial et L.A.T.S. Presse Med 1970;78:1535-1540. 13. Lamberg BA, Kivikangas V, Pelkonen R, et al: Thrombocytopenia and decreased life-span of thrombocytes in hyperthyroidism. Ann Clin Res 1971;3:98-102. 14. Takeda R, Funazu T, Odake K, et al: Idiopathic thrombocytopenic purpura associated with hyperthyroidism. South Med J 1973;66:553-556.Crossref 15. Dunlap DB, McFarland KF, Lutcher CL: Graves' disease and idiopathic thrombocytopenic purpura. Am J Med Sci 1974;268:107-111.Crossref 16. Vannasaeng D, Wasi P, Tandhanand S: Hyperthyroidism in association with idiopathic thrombocytopenic purpura. J Med Assoc Thai 1975; 58:97-105. 17. Dove AF, Petterson KG, Aronstam A: Idiopathic thrombocytopenic purpura and autoimmune thyroid disease. Practitioner 1977;218:550-552. 18. Getaz EP, Staples WG: Idiopathic thrombocytopenic purpura and hyperthyroidism. S Afr Med J 1977;52:284-285. 19. Herman J, Resnitzky P, Fine A: Association between thyrotoxicosis and thrombocytopenia. Isr J Med Sci 1978;14:469-475. 20. Resnitzky P, Schonfeld S, Dassa H: Effect of Graves' disease on idiopathic thrombocytopenic purpura. Arch Intern Med 1979;139:483-484.Crossref 21. Branehog I, Olson KS, Weingeld A, et al: Association of hyperthyroidism with idiopathic thrombocytopenic purpura and hemolytic anemia. Acta Med Scand 1979;205:125-131.Crossref 22. Axelrod AR, Berman L: The bone marrow in hyperthyroidism and hypothyroidism. Blood 1951;6:436-453. 23. Kurata Y, Nishioeda Y, Tsubakio T, et al: Thrombocytopenia in Graves' disease: Effect of T, on platelet kinetics. Acta Haematol 1980;63:185-190.Crossref 24. Hymes K, Blum M, Lackner H, et al: Easy bruising, thrombocytopenia, and elevated platelet immunoglobulin G in Graves' disease and Hashimoto's thyroiditis. Ann Intern Med 1981;94:27-30.Crossref 25. Schmidt GM, Bross KJ, Blume KG, et al: Detection of platelet-directed immunoglobulin G in sera using the peroxidase-anti-peroxidase (PAP) slide technique. Blood 1980;55:299-303. 26. Levy M, Cooper BA: Thrombocytopenic purpura associated with tuberculous lymphadenitis. Can Med Assoc J 1964;90:373-374. 27. Mueller-Eckhardt C: Idiopathic thrombocytopenic purpura (ITP): Clinical and immunologic considerations. Semin Thromb Hemostas 1977; 3:125-159. 28. Harrington WJ, Minnich V, Hollingworth JW, et al: Demonstration of a thrombocytopenic factor in the blood of patients with thrombocytopenic purpura. J Lab Clin Med 1951;38:1-10. 29. Shulman NR, Marder V, Weinrach R: Similarities between known antiplatelet antibodies and the factor responsible for thrombocytopenia in idiopathic purpura: Physiologic, serologic and isotopic studies. Ann NY Acad Sci 1965;124:499-542.Crossref 30. Steffen C: Untersuchungen uber die Verwendung der Antihumanglobin Ablenkungsmethode suz Nachweis von thrombozytenantikorpern. Wien Z Innere Med 1955;36:246-253. 31. Nelken D, Gurevitch J, Gilboa-Barber N: Direct antiglobulin consumption test for detection of immune antibodies. Lancet 1961;1:742-744.Crossref 32. Sandler RM, Voak D, Darnborough J: A simple method for detecting complement-fixation by autologous platelets in autoimmune thrombocytopenic purpura. Clin Lab Haematol 1981;3:61-70. 33. Van de Wiel TWM, van de wiel-Dorfmeyer H, van Loghem JJ: Studies on platelet antibodies in man. Vox Sang 1961;6:641-668.Crossref 34. Van Boxtel CJ, Oosterhof F, Engelfriet CP: Immunofluorescence microphotometry for the detection of platelet antibodies: III. Demonstration of autoantibodies against platelets. Scand J Immunol 1975;4:657-672.Crossref 35. Mueller-Eckhardt C, Mahn L, Schulz G, et al: Detection of platelet autoantibodies by a radioactive-anti-immunoglobulin test. Vox Sang 1978; 35:357-365.Crossref 36. Thompson P, Strum D, Boehm T, et al: Abnormalities of liver function tests in thyrotoxicosis. Milit Med 1978;143:548-551. 37. Weitzman SA, Stossel TP, Ridgway EC, et al: Antibodies to neutrophil thyrotropin (TSH) receptors in Graves' disease, abstracted. Clin Res 1980;28:498. 38. Segal BM, Weintraub MI: Hashimoto's thyroiditis, myasthenia gravis, idiopathic thrombocytopenic purpura. Ann Intern Med 1976;85:761-763.Crossref 39. Crabtree GR, Lee JC, Cornwell GG III: Autoimmune thrombocytopenic purpura and Hashimoto's thyroiditis. Ann Intern Med 1977;83:371-372.Crossref 40. Pinals RS, Tomar RH, Haas DC, et al: Graves' disease, myasthenia gravis, and purpura. Ann Intern Med 1977;87:250.Crossref 41. Wilson WA, Sissons JGP, Morgan OS: Multiple autoimmune disease with bilateral optic atrophy and lipodystrophy. Ann Intern Med 1978;89:72-73.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Aug 1, 1982

References