A 37-year-old Ghanaian female presented to the emergency department of our hospital with a complaint of palpitations, difficulty breathing, easy fatigue, and headaches. She had been referred from a peripheral hospital as a case of thrombocytopenia, severe anemia, and anterior neck swelling. Relevant past medical history included a diagnosis of Graves’ disease 2 years before this admission, for which she was put on antithyroid medication. Her family and psychosocial history were not of note. She became euthyroid during treatment but subsequently defaulted on her medications and long-term follow-up. Four months before her current admission, she noticed heavy menstrual bleeding with progressive weight loss. Four days before the presentation, the patient experienced dizziness, easy fatigue, profuse sweating, and tremors. At the referring hospital where she was initially admitted, she was transfused with whole blood after laboratory results showed anemia with hemoglobin (Hb) of 3.2 g/dl (normal: 11.5–16.5 g/dl) with mean corpuscular volume (MCV) of 79 fl (normal: 76–99 fl), white blood cell (WBC) count of 8.3 × 109/l (normal: 4–10 × 109/l) and platelet (PLT) count of 1 × 109/l (normal: 150–450 × 109/l). Physical examination showed bruising and ecchymosis all over her body and petechiae on her lower lips with gum bleeding. She had an anterior neck swelling that moved on swallowing, was diffuse, nontender, measured 3 × 3 cm, and with no thyroid bruit. There was exophthalmos demonstrated by the Naffziger sign. She also had a blood-soaked diaper with significant amounts of clots. All other examination systems were unremarkable. During admission, her initial blood pressure was 121/68 mmHg. She had a heart rate of 175 beats per minute with a weak and thready pulse, her respiratory rate was 40 cycles per minute, and peripheral oxygen saturation of 97% on oxygen via face mask at a flow rate of 6 liter/minute. On primary assessment, she was in severe respiratory distress and restless, severely pale, and had cold extremities with an axillary temperature of 36.5 °C. She was also noted to be bleeding per vaginum. Based on her laboratory results from the referral center (Hb: 3.2 g/dl and PLT: 1 × 109/l), she was immediately scheduled to receive fresh frozen plasma and packed cells. She, however, suffered a cardiac arrest during the initial assessment at the emergency. Cardiopulmonary resuscitation (CPR) was commenced and return of spontaneous circulation (ROSC) was achieved. She was subsequently sent to the high-dependency unit (HDU) after resuscitation for further assessment and management. A repeat complete blood count (CBC) showed a Hb of 5.4 g/dl, MCV of 82.5 fl, WBC count of 6.56 × 109/l, and PLT of 4.0 × 109/l. On admission day 2, her posttransfusion peripheral film comment indicated two populations of cells: microcytic hypochromic and normocytic normochromic red blood cells. Additionally, neutrophilia and markedly reduced platelets without clumping were seen. These findings were suggestive of multiple blood transfusions and probable autoimmune disease, and a diagnosis of ITP was considered. She was initially started on oral prednisolone 60 mg daily for 5 days, with a plan to gradually taper over a period of 4 weeks and supported with parenteral esomeprazole 40 mg 12 hourly, and tranexamic acid 1 g 8 hourly for 48 hours, while awaiting other laboratory test results. Hepatitis B and C virus and human immunodeficiency virus (HIV) serology were negative. Thyroid function testing revealed a low thyroid stimulating hormone (TSH) of 0.006 IU/ml (normal: 0.38–5.33 IU/ml), and elevated serum-free T3 of 9.2 pmol/l (normal: 3.5–7.8 pmol/l) and serum-free T4 of 42.1 pmol/l (7.9–18.5 pmol/l). The thyroid autoantibodies demonstrated elevated thyroperoxidase antibodies (TPOAb) levels of 58.91 IU/ml (normal: < 30 IU/ml), TSH receptor autoantibodies (TRAb) levels of 14.91 IU/l (normal: < 1.80 IU/l), and elevated thyroglobulin antibodies (TgAb) levels of 32.51 IU/ml (normal; < 4.11 IU/ml). An ultrasound of the thyroid revealed heterogeneous and hyperechoic glands of average size, with a mild increase in vascularity but no nodularity. A diagnosis of Graves’ disease-induced ITP was made, and she was commenced on oral propranolol 40 mg twice daily and oral methimazole 20 mg daily. The patient was followed-up at the endocrine and hematology clinics. Three weeks following admission, her thyroid function tests, Hb, and platelet results were all within normal limits. After 5 months of treatment and monitoring, TSH receptor autoantibodies were requested, and they were within normal limits (TRAb 0.05 IU/l). A summary of the patient’s CBC results from admission to her most recent review is presented in Table.