title: Atypical Complications of Graves' Disease: A Case Report and Literature Review.
abstract: Graves' disease (GD) may display uncommon manifestations. We report a patient with rare complications of GD and present a comprehensive literature review. A 35-year-old woman presented with a two-week history of dyspnea, palpitations, and edema. She had a raised jugular venous pressure, goiter, and exophthalmos. Laboratory tests showed pancytopenia, a raised alkaline phosphatase level, hyperbilirubinemia (mainly direct bilirubin), and hyperthyroidism [TSH: <0.01 mIU/L (reference values: 0.45-4.5), fT4: 54.69 pmol/L (reference values: 9.0-20.0), and fT3: >46.08 pmol/L (reference values: 2.6-5.7)]. Her thyroid uptake scan indicated GD. Echocardiography showed a high right ventricular systolic pressure: 60.16 mmHg. Lugol's iodine, propranolol, cholestyramine, and dexamethasone were initiated. Hematologic investigations uncovered no reason for the pancytopenia; therefore, carbimazole was started. Workup for hepatic impairment and pulmonary hypertension (PH) was negative. The patient became euthyroid after 3 months. Leukocyte and platelet counts and bilirubin levels normalized, and her hemoglobin and alkaline phosphatase levels and right ventricular systolic pressure (52.64 mmHg) improved. This is the first reported single case of GD with the following three rare manifestations: pancytopenia, cholestatic liver injury, and PH with right-sided heart failure. With antithyroid drugs treatment, pancytopenia should resolve with euthyroidism, but PH and liver injury may take several months to resolve.
authors.affiliation: Endocrine Department, Hamad Medical Corporation, Doha, P.O. Box 3050, Qatar.
authors.forename: Khaled Ahmed
authors.identifier: 0000-0003-0577-2694
authors.initials: KA
authors.lastname: Baagar
authors.affiliation: Endocrine Department, Hamad Medical Corporation, Doha, P.O. Box 3050, Qatar.
authors.forename: Mashhood Ahmed
authors.initials: MA
authors.lastname: Siddique
authors.affiliation: Endocrine Department, Hamad Medical Corporation, Doha, P.O. Box 3050, Qatar.
authors.forename: Shaimaa Ahmed
authors.initials: SA
authors.lastname: Arroub
authors.affiliation: Emergency Department, Hamad Medical Corporation, Doha, P.O. Box 3050, Qatar.
authors.forename: Ahmed Hamdi
authors.initials: AH
authors.lastname: Ebrahim
authors.affiliation: Endocrine Department, Hamad Medical Corporation, Doha, P.O. Box 3050, Qatar.
authors.forename: Amin Ahmed
authors.initials: AA
authors.lastname: Jayyousi