We report on a 39-year-old Filipino man who presented to our facility with a 2-week history of headache, easy fatigability, and on-and-off gum bleeds that stopped spontaneously associated with palpitation tremors and unintentional weight loss. He had a history of hypertension diagnosed 2 years ago. Upon presentation, the patient was conscious, alert, oriented, afebrile, and vitally stable. He seemed slightly pale but without signs of thyroid eye disease. His neck exam showed enlarged thyroid glands but no palpable lymphadenopathy. His hands were sweaty moist and warm with coarse upper-extremity tremors. His chest abdomen and neurological exams were all normal. His blood works and peripheral smear were suggestive of pancytopenia with severe macrocytic anemia and reticulocytopenia.
The patient's initial blood test results showed a hemoglobin level of 5.5 g/dL (lab reference range: 13-17), his white blood cell level was 2.2 x 103 U/L (reference range: 4-10 x 103), and his platelet count was 30 x 103 U/L (reference range: 150-400).
Other lab works, including iron profile, folate, vitamin B12, haptoglobin, lactate dehydrogenase, and liver function test, were normal. Hepatitis B and C virus, HIV screen, parvovirus B19 serology, and autoimmune disease work-up were done as part of the pancytopenia work-up, all returned normal. CT of the chest/abdomen and pelvis with contrast showed no organomegaly evidence of malignancy. Peripheral blood smear showed severe macrocytic anemia with anisopoikilocytosis including scattered macrocytes, ovalocytes, tear drop target cells, some spherocytes and schistocytes, basophilic stippling, and few polychromatic cells. We found leukopenia with moderate neutropenia, mild toxic features, few and reactive lymphocytes, and severe thrombocytopenia. Bone marrow exam suggested hypocellular bone marrow with low numbers of megakaryocytes and decreased granulopoiesis with orderly maturation up to the segmented stage. Blast cells were 3%. Erythropoiesis appeared active with a mixture of normoblastic and megaloblastic maturation. No significant dysplasia was found, normal cytogenetics and no increased blast cells.
The patient was started on supportive transfusions with packed red blood cells and platelets. He required almost weekly transfusions. Then, the patient was started on cyclosporin 125 mg BID daily. During his hospital stay, the patient was found to have hyperthyroidism with suppressed TSH of <0.01 mIU/L (reference range: 0.45 4.50) T4 45.4 pmol/L (9-20), T3 15.35 pmol/L (2.6-5.7), and anti-TBO (thyroid peroxidase negative and anti-thyroglobulin antibody negative). A scan of his thyroid glands showed diffuse uptake suggestive of Gravies' disease. The patient was started on propranolol and methimazole, but he was not compliant with his medications so radioactive iodine ablation was done. After which the patient became hypothyroid and was started on levothyroxine replacement 100 mug daily.
After radioactive iodine ablation and thyroid disease control, the patient's red blood cell and platelet transfusion requirement markedly decreased, and his blood counts improved. Cyclosporine was gradually tapered until it was completely stopped after 16 months. Currently, our patient does not require any red blood cell or platelet transfusions. His anemia symptoms have resolved. His follow-up includes close blood count monitoring. During his most recent follow-up, he had a hemoglobin level of 15 g/dL, white blood cell count of 5.4, and platelet count of 38. Repeat bone marrow exam after 2 years of diagnosis suggested cellular bone marrow with trilineage hematopoiesis and areas of reduced cellularity.