Resident Physician Osceola Regional Medical Center Oviedo, Florida, United States
Introduction : Graves' disease is a localized autoimmune disorder characterized by hyperstimulation of the thyroid function via the thyroid receptor antibodies. Previous studies have suggested that abnormalities in thyroid stimulating hormone are associated with harmful effects on the cardiovascular system. Pericardial effusions are more common with hypothyroidism. In this case we present a patient with pericardial effusion secondary to pericarditis and pleural effusion in the setting of thyroid storm, which is a rare complication.
Case(s) Description : A 71-year-old man with uncontrolled Graves' disease with ophthalmology, atrial fibrillation (Afib), and congestive heart failure presented to the hospital with complaints of chest pain worsen by supine position and shortness of breath for two weeks. No recent respiratory infections reported. EKG showed Afib with rapid ventricular response with a heart rate of 140. Laboratory studies showed undetectable TSH, elevated FT4, normal T3, and elevated CRP. The Burch- Wartofsky Point Scale was 55, highly suggestive of thyroid storm. Echocardiogram showed a large pericardial effusion and chest X ray showed left sided pleural effusion. Pericardiocentesis was completed and 1.2L was removed. Thoracentesis removed another 1.2L of pleural fluid. Fluid analysis showed exudate which could be secondary to diuretic use. No malignancy detected. Since his diagnosis of Graves' disease in 2008, he had been treated with methimazole but still clinically hyperthyroid even after multiple adjustments in medication dose, mainly because of leukopenia. His dose of methimazole was increased to 20mg during his hospital stay, ibuprofen and colchicine were initiated, and he was encouraged to complete thyroidectomy to achieve euthyroid state and help prevent recurrence of pericarditis and pericardial/pleural effusions. Two months later, his hyperthyroidism is better controlled, and he had no recurrence.
Discussion : Common cardiac complications associated with Graves' disease include Afib, cardiomyopathy, and hypertension. Pericarditis and pericardial effusion are mostly associated with hypothyroidism. There are some case reports that have shown association between pericardial disease, pleural effusion, and hyperthyroidism. This case emphasizes the importance of considering thyrotoxicosis in the differential diagnosis of pleural or pericardial effusions, as it is treatable, and recurrences or progression can be preventable. This case also illustrates the importance to achieve euthyroid state with medications, or thyroidectomy if indicated, for long term prevention of life-threatening complications.
