Graves's disease is an autoimmune disease characterized by hyperthyroidism due to circulating autoantibodies. Thyroidstimulating immunoglobulins (TSIs) bind to and activate thyroid-tropin receptors, causing the thyroid gland to enlarge and the thyroid follicles to produce more thyroid hormone. In certain individuals, Graves's disease may be a component of more widespread autoimmune conditions that affect several organs (such as polyglandular autoimmune syndromes). Pernicious anemia, vitiligo, diabetes mellitus type 1, systemic sclerosis, myasthenia gravis, Sjogren syndrome, rheumatoid arthritis, and systemic lupus erythematosus are all linked to Graves's disease. A few instances of this uncommon and little-known "entity" have been reported. Herein, I describe the association of Graves's disease associated with pancytopenia and splenomegaly response to steroid therapy. We suggest that such an association has been very rarely reported. Case study: A 55-year-old Sudanese male presented to us at ELmek Nimer University Hospital complaining of generalized fatigability with symptoms and signs of Graves ' disease. He also looked pale on the abdominal examination; there was a huge splenomegaly, a complete blood count showed features of pancytopenia, and all components of blood and cells were low. We diagnosed him with autoimmune thyroid disease associated with splenomegaly and started treatment with steroids, which showed improvement clinically and in the laboratory. In Graves' disease, four well-known thyroid antigens are known to be targets of B and T lymphocyte-mediated autoimmunity: thyroglobulin, thyroid peroxidase, sodiumiodide symporter, and thyrotropin receptor. Nonetheless, the thyrotropin receptor itself is the main autoantigen of Graves's disease, and it also results in hyperthyroidism. The immune responses specific to the thyroid antigen mediated by antibodies and cells are well-defined in this disease. The development of hyperthyroidism in healthy subjects by transfer of thyrotropin receptor antibodies in serum from patients with Graves's disease and the passive transfer of thyrotropin receptor antibodies to the fetus in pregnant women are direct indications of an autoimmune disorder mediated by autoantibodies. We recommend that steroid 'therapy' should be considered as one of the modalities in the management of pancytopenia, splenomegaly associated with Graves's disease, in combination with ant-thyroid treatment.

1.    Kim TH, Yoon JS, Park BS, et al.  A case of pancytopenia with hyperthyroidism YUJM 2013; 30:47-50.
2.    Lima CS, Wittmann DE, Catro V, et al. Pancytopenia in untreated patients with Graves disease. Thyroid 2006; 16:403-409. 
3.    Weetman AP. Graves disease N Engl J Med 2000; 343: 1236-1248.
4.    Soeki T, Takamura Y, Kondo N, Shinohara H, Tanaka H, Bando K, et al. A case of thyrotoxicosis with pancytopenia. Endocr J. 2001; 48: 385-9
5.    Akasheh MS. Graves disease mimicking beta-thalassemia trait. Postgrad Med J. 1994 Apr; 70(822): 300-301.
6.    Akoum R, Michel S, Wafic T, Emile B, Marwan M, Khaled H, et al. Peripheral blood and bone marrow analysis before and after antihormonal treatment for myelodysplastic syndrome and pancytopenia responding to hyperthyroidism treatment. J Can Res Ther. 2007; 3(1):43-46.
7.    Ahmed MOHS. Atypical clinical manifestations of Graves disease: an analysis in dept. Hindawi Publishing Corporation Journal of Thyroid Research 2012.
8.    Ohtsuka R, Abe Y, Shiratsuchi M, et al. Graves disease is splenomegaly and pancytopenia, mimicking B-cell lymphoproliferative disease Rinsho Ketsueki. 2008; 49: 104-108
9.    Raina S, Kaul R, Mruthyunjaya M. Pancytopenia with cellular bone marrow related to Graves hyperthyroidism Indians J Endocrinol Metab. 2012; 16(3): 478-479.
10.    Low BH, Kok VCK. Hyperthyroidism with Pancytopenia: A Case Report and Literature Review. Formos J Endocrinol Metab.2009; 1(1): 23-8.
11.    Naji P, Kumar G, Dewani S, Diedrich WA, Gupta A. Graves Disease causing pancytopenia and autoimmune hemolytic anemia at different intervals: a case report and a literature review. Hindawi Publishing Corporation. Case Reports in Medicine. 2013.
12.    Heng LH, Tan F. Pancytopenia in a patient with Graves Disease. Med J Malaysia 2013; 68 (4): 372-3.
13.    Duquenne M, Lakomsky D, Humbert JC, Hadjadj S, Weryha G, Leclere J. Resolutive pancytopenia with effective treatment of hyperthyroidism. Presse Medicale. 1995; 24(17): 807-810.
14.    Muroi K 1, Sakuma Y, Izumi T, Sato K, Tanaka Um, Ozawa K. An extended period of extramedullary hematopoiesis, splenomegaly, and leukocytopenia without clinically evident rheumatoid arthritis. Hematology Clin Exp 2010; 50(2):163-6.
15.    Shah A, Diehl LF, St Clair EW. T cell large granular lymphocyte leukemia associated with rheumatoid arthritis and neutropenia. Clin Immunol. 2009; 132: 145-152
16.    OReilly RA. Splenomegaly in 2505 patients at a large university medical center from 1913 to 1995.WJM 1998; 169(2): 78-87.
17.    Silva M, Vieira R, Bessa MM, Lima JKT, Marques TF A rare Graves disease case with splenomegaly and pancytopenia. Int Arch Med48:385-389. 2017 ;( 10):1755-7682
18.    Soeki T, Tamura Y, Kondo N, et al. A case of thyrotoxicosis with pancytopenia. Endocr J. 2001; 48:385-389
19.    Duquenne M, Lakomsky D, Humbert JC, Hadjadj S, Weryha G, Leclère J. Pancytopenia resolved by the treatment of hyperthyroidism Presse Med. 1995; 24:807-810.