Hashimoto's thyroiditis associated Evans syndrome: A rare case report on the clustered autoimmune disease triad
A 34-year-old female, who is a known case of Hashimoto's thyroiditis, on synthetic thyroid hormone intake (50 μg/day) since five years, presented with high-grade intermittent fever associated with chills and rigors, headache, and breathlessness. There was no significant family history of thyroid disease and she was on no other medication except for the thyroxine intake. On examination, the patient was disoriented, looked pale with anemic conjunctiva, and icteric sclera. Her blood pressure was 110/90 mm of Hg, body temperature was 101°F, and pulse rate was 120 per minute. She had minimal, firm thyromegaly, tenderness in the right hypochondrium, and mild splenomegaly, on an ultrasound scan of the abdomen. There were neither enlarged peripheral lymph nodes nor any enlargement of them on the abdominal ultrasound scan. There were no signs or symptoms of overt hypothyroidism. Further investigations were negative for malaria, hepatitis B surface (HBs) antigen, hepatitis C virus (HCV) antibody, Dengue, HIV, Syphilis, and Leptospirosis. Antinuclear antigen (ANA) and “Anti-ds DNA” were negative. She had low hemoglobin, hematocrit, red blood cells (RBC), and platelet count along with high mean corpuscular volume (MCV). Peripheral blood smear examination showed a marked anisocytosis comprising of macrocytes, polychromatic cells, and microspherocytes. A high percentage of nucleated RBC and thrombocytopenia were also seen []. There were no hemoparasites or abnormal cells.\nBone marrow aspiration was done to rule out any underlying lymphoproliferative conditions and the slides showed only hypercellular marrow with erythroid hyperplasia and increased megakaryopoiesis []. The overall impression on hematological examination was hemolytic anemia with thrombocytopenia and reactive marrow hyperplasia. We performed a further workup and the results are shown in . To summarize, the patient had a positive direct antiglobulin test, evidence of hemolysis in the form of reticulocytosis, elevated indirect bilurubin, and serum lactate dehydrogenase (LDH). She also had increased anti-thyroid peroxidase antibody levels. The constellation of the clinical and laboratory data suggested that the patient was a case of Hashimoto's thyroiditis complicated by Evans syndrome. The patient was put on corticosteroids and she showed a significant improvement. She was now on a followup for six months. Her present hemoglobin is 13.2 grams% and total serum bilirubin is 0.8 mg/dl.