Pericardial Effusion Complicating Graves’ Disease In Pregnancy

Authors: Hannah C. Urbanozo1, Marcelyn A. Fusilero2, Marc Gregory Y. Yu3, Cherrie Mae C. Sison1

1 Section of Endocrinology, Diabetes and Metabolism, University of the Philippines-Philippine General Hospital, Department of Medicine, Manila, Philippines

2 Section of Cardiology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines

3 Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines

Cardiovascular alterations in the thyrotoxic patient are attributed to hypermetabolism and the need to dissipate the excess heat produced, which results to increased circulatory demands.  While sinus tachycardia, atrial fibrillation and congestive heart failure with long-standing atrial fibrillation are well-recognized cardiovascular manifestations of thyrotoxicosis, the occurrence of pericardial effusion due to thyrotoxicosis is rarely reported.

We report the case of a 32-year-old Filipino woman in the 23rd week of her fourth pregnancy, with a seven-year history of a gradually enlarging anterior neck mass associated with palpitations, exophthalmos, heat intolerance and easy fatigability.  She was treated as a case of thyroid storm on initial presentation at the emergency room, with a baseline FT4 of 40.2 pmol/L and TSH of 0.1 uIU/ml and subsequently discharged.  She developed exertional dyspnea, 3-pillow orthopnea and bipedal edema without associated chest pain or fever, days after discharge.  Echocardiogram on readmission revealed massive pericardial effusion in tamponade.  Her FT4 upon at this time was within normal limits.  Immediate pericardiostomy was done.  Pericardial fluid was negative for mycobacterium tuberculosis or any bacterial isolates.  Serum ANA was likewise negative.  After initial pericardiostomy and treatment with anti-thyroid medications and prednisone, pericardial effusion resolved.

Table 1: Pericardial Fluid Studies

Qualitative Examinations

Result

Color

Dark red

Transparency

Slightly hazy

Red Blood Cells

283,000 x 106/L

White Blood Cells

578 x 106/L

Polymorphonuclear Cells

82%

Lymphocytes

17%

Distorted Cells

0.01%

Glucose

4.95 mmol/L

Total Protein

59.01

Gram Stain

PMN 0-1/OIF

Gram positive cocci in pairs 0-1/OIF

Bacterial Culture

No growth

AFB Smear

Negative

AFB Culture

No growth

Cytology

A repeat 2decho upon follow-up showed no residual effusion.  To date, there are no published cases in the Philippines on thyrotoxic pericardial effusion.

In a thyrotoxic patient with worsening heart failure symptoms despite adequate treatment, it is prudent to consider a pericardial effusion, to facilitate timely management.

Fig. 1.  Chest radiograph on 1st admission, with LV cardiomegaly

trapago xray1

Fig. 2.  Chest radiograph on 2nd admission showing water-bottle shaped cardiomegalytrapago xray2

References:

Kahaly G, Dillmann W. Thyroid Hormone Action in the Heart. Endocrine Reviews. 2005. 26(5):704–728.

Sampana A, Jasul G. High Grade AV Block Complicating Hyperthyroidism: A Case Report. Philippine Journal of Internal Medicine July-Septemner 2010; 48:2.

Braunwald E, Fauci AS, Kasper D, Hauser HL, Longo D, Jameson JL. Disorders of the thyroid gland. In: Braunwald E, Fauci AS, Kasper D, Hauser HL, Longo D, Jameson JL, editors. Harrison’s principles of internal medicine. 15th ed. Vol 2. New York: McGraw-Hill; 2001. p. 2069-73.

Ovadia, S, Lysy y L, Zubkov T. Pericardial effusion as an expression of thyrotoxicosis. Tex Heart Inst J 2007; 34:88-90.

Teague E, O’Brien C, Campbell N. Pericardial effusion and tamponade complicating treated Graves’ thyrotoxicosis. Ulster Med J 2009; 78 (1) 56-58.

Nakata A, Komiya R, Ieki Y, Yoshizawa H, Hirota S, Takazakura E. A patient with Graves’ disease accompanied by bloody pericardial effusion. Internal Medicine 2005; 44(10):1064-1068.)

Levy PY, Corey R, Berger P, Habib G, Bonnet JL, Levy S, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003; 82: 385-91.

3 thoughts on “Pericardial Effusion Complicating Graves’ Disease In Pregnancy

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