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



Dark red


Slightly hazy

Red Blood Cells

283,000 x 106/L

White Blood Cells

578 x 106/L

Polymorphonuclear Cells




Distorted Cells



4.95 mmol/L

Total Protein


Gram Stain


Gram positive cocci in pairs 0-1/OIF

Bacterial Culture

No growth

AFB Smear


AFB Culture

No growth


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


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