Cardiac Tamponade in a Patient with Severe Graves' Disease

Saturday, May 14, 2022

10:10 AM – 10:25 AM

Location: Station 1, Sapphire West Foyer

Submitter(s)

JP
Jose Paz-Ibarra, Sr., MD, PhD, Professor
Endocrinologist / Professor
Hospital Nacional Edgardo Rebagliati Martins / Universidad Nacional Mayor de San Marcos
Lima, Peru

Primary Author(s)

JP
Jose Paz-Ibarra, Sr., MD, PhD, Professor
Endocrinologist / Professor
Hospital Nacional Edgardo Rebagliati Martins / Universidad Nacional Mayor de San Marcos
Lima, Peru

Introduction : Pericarditis is frequently encountered in clinical practice. Common causes of acute pericarditis include infections, myocardial infarction, malignancies, and autoimmune disorders. We present the case of a patient who presented with pericarditis secondary to Graves´ disease (GD).

Case Description : A 16-year-old female, with no significant family or epidemiological history. She attended the emergency room with a period of three days of illness characterized by dyspnea and orthopnea, palpitations, dry cough, sensation of thermal rise not quantified, chest tightness without radiation and edema of the lower limbs. On physical examination: Lethargic, HR 150 bpm, BP 120/80mmHg, temperature 37º, Sat O₂ (FiO₂ 0.21) 92%, vesicular murmur decreased in both bases, heart sounds decreased in tone, jugular engorgement. The EKG showed atrial fibrillation (AF) with high ventricular response and low-voltage QRS complexes with electrical alternation. Pharmacological cardioversion of AF and supplemental oxygen administration were performed, an ultrasound examination revealed severe pericardial effusion, after unsuccessful pericardiocentesis the patient underwent creation of a pleuropericardial window. The pericardial fluid analysis was compatible with exudate, the ADA test in pericardial fluid: 16 U/L (VN: < 20). She was transferred to the ICU and required mechanical ventilation, broad-spectrum antibiotic treatment, and vasoactive amines. TSH < 0.004 uIU/ml, FT4: 3.54 ng/dl, Anti-TPO 409 IU/ml (VN: < 35), Anti-TG 209 IU / ml (VN: < 40). The results confirmed hyperthyroidism by GD, the Burch-Wartofsky Scale and the Japanese Thyroid Association confirmed thyroid storm. Serial ANA, ANCA, and BK in sputum, urine, stool, gastric aspirate, pleural fluid, and pericardial fluid were negative.

Thyroid ultrasound showed diffuse hypervascularized goiter, and 99mTc scintigraphy revealed diffuse hyper-uptake goiter.

The pericardial biopsy evidenced chronic granulomatous pericarditis with reactive mesothelial cells concluded: fibrinous pericarditis, negative BK staining .

The patient evolved favorably, she was hospitalized for 45 days, with a progressive resolution of the symptoms with medical treatment with antithyroid drugs and beta-blockers; She subsequently received treatment with ¹³¹I which controlled her hyperthyroidism and the pulmonary and pericardial ultrasound did not show effusion in the follow-up.

Discussion : Pericarditis has been identified as a rare complication of thyrotoxicosis and has only been poorly reported in the literature. To date there are approximately 20 case reports that suggest a relationship between pericardial disease and thyrotoxicosis. Pericardial involvement in hyperthyroidism can manifest with spectra of disease that vary by pericarditis with and without effusion, cardiac tamponade, or even myopericarditis with or without hemodynamic instability.