Case Presentation: 33-year-old female with no significant past medical history presented to an outside hospital with complains of abdominal pain, nausea, vomiting, night sweats and dark urine. She was found to have Systemic inflammatory response syndrome and an initial diagnosis of UTI was made. Patient was started on empiric antibiotics. Further laboratory work up was significant for pancytopenia with WBC 3.3, hemoglobin 6.0 and platelet count 14000. Patient was transferred to our tertiary care center for further care. She was found to have microangiopathic hemolytic anemia along with hematuria, proteinuria and low vitamin B12 levels on additional workup. Given high clinical suspicion for TTP, ADMATS 13 was obtained and patient was urgently started on plasma exchange and high dose prednisone. ADAMTS13 levels resulted as < 3% and diagnosis of TTP was confirmed. Caplacizumab was added to therapeutic regimen. Systemic inflammatory response syndrome persisted with infectious work up negative and despite TTP therapies. On further review of her previous medical records, an old CT chest from 9 months ago she was reported to have incidental thyromegaly and additional work up was advised at that time but never obtained. Thyroid function tests consistent with hyperthyroidism. Diagnosed of grave’s disease was established with an elevated thyrotropin receptor antibody. Endocrinology consulted and patient was started on methimazole and beta blocker therapies leading to improvement in SIRS. Her cell counts recovered and she was discharge home in stable condition.
Discussion: Thrombotic thrombocytopenic purpura is a rare blood disorder with a high mortality and morbidity. Prompt treatment with plasma exchange has shown to significantly reduce mortality. Triggers for both inherited and acquired etiologies can be variable. Certain conditions likely cancer, HIV, autoimmune disorders, infections and medicines are known to be associated with TTP. Graves disease have been described as a very rare trigger of TTP in limited medical literature and association seems to be more than coincidental. Graves disease has been reported to be associated with relapse of TTP and a causal link is also supported by one of the case reports describing remission of TTP after successful treatment of hyperthyroidism.
Conclusions: Clinicians should be aware about this potential association and screen patient with TTP for Graves disease. Additionally hyperthyroid patient with unexplained drop in platelets should also be raise a suspicion and consideration of TTP.