A case report of immune thrombocytopenic purpura as a rare Harbinger of Graves’ disease

Graves’ disease is one of the most common forms of autoimmune hyperthyroidism and has been linked with multiple or family histories of autoimmune diseases. In most cases, Graves' disease diagnosis is easily made by recognizing goiter, ophthalmopathy, and hyperthyroid symptoms. However, in some cases, the symptoms are atypical and potentially be misdiagnosed. We presented a patient with immune thrombocytopenic purpura as an initial symptom of Graves' disease in a patient with family history of Graves' disease. A-27 year-old man came to the emergency department due to recurrent epistaxis since two weeks ago. The patient was diagnosed with ITP a year ago, but discontinued his medication by himself. His platelet count was 4000/μL with negative results of HBV, HBC, HIV, and ANA tests. His mother was going on Graves' disease medication for 15 years, but no goiter or ophthalmopathy was observed. His vital sign was constantly raised, and meticulously examination by Wayne score revealed hyperthyroidism, that were confirmed by raised T4 and decreased TSH level. Graves' disease diagnosis was established by the increasing of TRAb. The patient was then treated concurrently for his ITP and Graves’ disease, which showed excellent improvement. Immune thrombocytopenia purpura could be the only initial symptom of Graves' disease, especially in a patient with family history of Graves' disease. Autoimmune diseases tend to be clustered not only in a family, but also in an individual. Although ITP in Graves's disease reflect more severe thrombocytopenia, euthyroid states by propylthiouracil medication in combination with standard ITP therapy resulting an excellent outcome.