Pericarditis and pericardial effusion are commonly associated with hypothyroidism. It is an uncommon association with hyperthyroidism. We present a case of pericarditis/pericardial effusion in a 28-year-old Nigerian lady with hyperthyroidism. There was resolution of the pericardial effusion with antithyroid&nbsp; medications and steroid therapy. We recommend a high index of suspicion of this association in patients&nbsp; with hyperthyroidism and/or Graves’ disease

Adebiyi, A.

Aje, A.

Bakare, T.A.

Fabowale, M.O.

Kehinde, A.M.

Obasuyi, V.

Ogah, O.S.

Okafor, I.J.

Olusola, F.I.

Orimolade, O.O.

English

PubMed

AJOL - African Journals Online

                                                   Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021   78INTRODUCTIONHyperthyroidism is a syndrome associated with excessthyroid hormone production. Patients typically presentwith irritability, unintentional weight loss, heatintolerance, malaise, diaphoresis, gastrointestinal hyper-motility and diarrhoea. Cardiovascular complicationsof  hyperthyroidism include high or normal outputheart failure, arrhythmias and tachycardia-associatedcardiomyopathy.1, 2Pericardial effusion is rare in hyperthyroidism whencompared to hypothyroidism. Autoimmunepericarditis has been reported in Graves’ disease.3PERICARDIAL EFFUSION IN A PATIENT WITH HYPERTHYROIDISM:A CASE REPORTM.O. Fabowale1, O.S. Ogah1,2,3 , A.M. Kehinde1, F.I. Olusola1, I.J. Okafor1, T.A. Bakare1,V. Obasuyi1, O.O. Orimolade1, A. Aje1, and A. Adebiyi1,21. Cardiology Unit, Department of  Medicine, University College Hospital, Ibadan, Nigeria.2. Cardiology Unit, Department of  Medicine, University of  Ibadan, Ibadan, Nigeria.3. Institute of  Advanced Medical Research and Training, College of  Medicine, University of  Ibadan, Nigeria.Correspondence:Dr. O.S. OgahCardiology Unit,Department of Medicine,University College Hospital,Ibadan,E-mail: osogah56156@gmail.comABSTRACTPericarditis and pericardial effusion are commonly associated withhypothyroidism. It is an uncommon association with hyperthyroidism. Wepresent a case of pericarditis/pericardial effusion in a 28-year-old Nigerianlady with hyperthyroidism. There was resolution of the pericardial effusionwith antithyroid medications and steroid therapy. We recommend a high indexof suspicion of this association in patients with hyperthyroidism and/orGraves’ disease.Keyword: Thyroid disease, Hyperthyroidism, Pericarditis, Pericardial effusionHerein, we present the case of a 28-year-old womanwho was admitted with features of hyperthyroidismand pericardial effusion, the effusion resolvedfollowing treatment of hyperthyroidism.CASE REPORTA 28-year-old lady presented to the Medical OutpatientClinic of our hospital on account of a three-monthshistory of recurrent palpitations, easy fatigability andexertional dyspnea. Palpitations occur most times ofthe day but worse at rest. There was history diaphoresisbut no chest pain or pressure like sensations on theFigure 1: 12-lead ECG of the patientAnn Ibd. Pg. Med 2021. Vol.19, No.1 78-81                                                   Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021   79chest. No history of headaches, blurring of vision,feeling of  impending doom or syncopal attacks. Shehowever reported malaise, easy fatigability anddyspnoea on exertion which later progressed todyspnoea even at rest. She denied any report of cough,paroxysmal nocturnal dyspnea, orthopnoea orrecurrent pedal oedema. She had no precedingsymptoms of upper respiratory tract infection orbackground anxiety disorder. She also has unintentionalweight loss, early satiety and loss of appetite. Therewas associated recurrent effortless postprandialvomiting with vague abdominal pain and hyper-defecation. She reported tremors, heat intolerance andscanty menses. She did not have dysphagia or changein her voice.Blood Reference Range In this hospitalHaemoglobin(g/dl) 12.0-16.0 10.9White cell count (mm3) 4,000-11,000 11,720Neutrophils (%) 37-72 49.5Lymphocytes (%) 20-50 39.2Platelet count (/mm3) 150,000-400,000 313,000Sodium (mmol/L) 135-145 137Potassium (mmol/L) 3.5-5.0 3.4Chloride (mmol/L) 95-110 97Bicarbonate (mmol/L) 20-30 25Urea (mg/dl) 15-45 16Creatinine (mg/dl) 0.5-1.5 0.3Thyroid Function TestTSH (mlU/L) 0.270-4.20 0.056T4 (pmol/L) 12-22 96.8T3 (pmol/L) 3.9-6.7 31.8UrineGlucose NegativeProtein NegativeBlood NegativeBilirubin NegativeKetones NegativeUrobilinogen NormalNitrite NegativeSG 1.010-1.035 1.015pH 5.0-9.0 6.0Table 1: The laboratory panel of  the patient.Figure 2: Two-dimensional echo showing the pericardial effusion with fibrinous materials.EFF= Effusion, LA= left atrium, LV= Left ventricle                                                   Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021   80At presentation, she was restless, diaphoretic and mildlydehydrated. She was not febrile, not pale, anicteric,not cyanosed and had no digital clubbing. She had nosignificant peripheral lymphadenopathy and no pedaledema. There was an anterior neck swelling measuring4 x 6cm but more to the right side. The swelling wasfirm in consistency with irregular edges, non-tenderand no differential warmth. There was noexophthalmos or lid lag. There were fine tremors. Shewas dyspneic, respiratory rate was 36 breaths perminutes, trachea was central and breath sound werevesicular bilaterally. Her pulse was 112/min andregular, BP 120/70mmHg, JVP was not elevated andapex beat was difficult to localize. First and SecondHearts sounds were heard with pericardial friction rub.She was conscious, alert, oriented in time place andperson, pupils 3mm equal, round, bilaterally reactiveto light, no cranial nerve deficit, no sign of  meningealirritation, normal muscle bulk, tone and reflexes.She was admitted for evaluation. Imaging studiesrevealed a relatively normal chest with a normalmediastinal contour. Table 1 shows the investigationresults. The ECG (Figure 1) showed sinus tachycardia.Echocardiography (Figure 2) revealed a pericardialeffusion over the left ventricle with fibrinous strandsin the pericardial cavity.She was commenced on oral medications whichincludes prednisolone 40mg daily, propranolol 20mgb.d., rabeprazole 20mg daily and carbimazole 15mgb.d. She had made significant improvement on followup clinic appointments.DISCUSSIONAtrial fibrillation, thyrotoxic cardiomyopathy,pulmonary arterial hypertension, systemic hypertensionand high or normal output heart failure are knowncardiac complications of hyperthyroidism. The patientdiscussed had normal left ventricular function onechocardiography and ECG did not show any featuresof atrial fibrillation. An ongoing malignancy andinfection especially tuberculous pericarditis was alsoconsidered but this was excluded by the absence ofsuggestive clinical picture and laboratory profile.The possibility of pericardial effusion/pericarditisbeing a possible complication of hyperthyroidism wasentertained after review of some case reportssuggesting a rare relationship between pericardialdisease and hyperthyroidism.4  The earliest case to havebeen reported was in 1958. Koo et al.3 reported a caseof acute recurrent pericarditis that was presumed tobe associated with Graves’ disease based onpathological background of the disease and resolutionof symptoms following treatment of hyperthyroidism.There have been different arguments as to whether itis a mere coincidence or a cause- effect relationship.Some authors believe that pericardial involvement inhyperthyroidism may present with pericarditis withouteffusion, myopericarditis or cardiac tamponade5. Thegeneral consensus is that, the immunologicalmechanism which explains pre-tibial, periorbitalmyxedema and ophthalmic myopathy could be at playin pericardial effusion caused by hyperthyroidismespecially in patients with Grave’s disease. 6Autoantibodies or viral infection (Epstein Barr Virusin most cases) involved in Graves’ disease can initiatean inflammatory process within the pericardium byinteracting with its receptors. 7-10Clarke et al.6 reported four middle-aged patients withGraves’ disease associated with pericardial disease.They opined that pericardial disease could be a rarecomplication of Graves’ disease and may have similarmechanism of  action with that of  Grave’s associatedophthalmomyopathy and dermopathy. Most casereports presented typical acute pericarditis who onfurther evaluation were found to have thyrotoxicosis.On the other hand, some cases reported thedevelopment of acute pericarditis in patients withestablished diagnosis of Graves’ disease on treatment.However, it was suggested that single episodes ofpericarditis with Graves’ thyrotoxicosis could notexplain the pathophysiology, as you would expect thatautoimmune forms of  pericarditis should be recurrentbut this was not the case in most reports.2 Acutethyrotoxicosis may directly impact pericardial fatmetabolism making it a possible alternate cause ofpericarditis.11 In some clinical scenarios, there were casesof drug-induced pericarditis following commencementof  propylthiouracil for treatment of  thyrotoxicosis.Drug induced vasculitic syndrome was singled out asa possible mechanism12. Pericarditis has also beendescribed after the initiation of other anti-thyroidmedications like iodine and carbimazole. In patientswith pericardial effusion/pericarditis, there is need torule out hyperthyroidism as a possible aetiology,especially in patients with clinical features that aresuggestive. In our case, symptoms resolved followingtreatment for hyperthyroidism.REFERENCES1. Tsai A. Thyroid Woes. Diabetes Forecast.2016;69(1):58-62.2. Ertek S, Cicero AF. Hyperthyroidism andcardiovascular complications: a narrative reviewon the basis of  pathophysiology. Archives ofmedical science: AMS. 2013; 9(5):944.3. Koo EH, Kim SM, Park SM et al. Acute RecurrentPericarditis Accompanied by Graves’ Disease.Korean circulation journal. 2012; 42(6):419-422.                                                   Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021   814. Kortekaas K, van der Lienden B, Jong S et al.Graves’ disease as an uncommon cause of acutepericarditis. Case Reports. 2014; 2014: bcr2013203342.5. Gupta P, Chhabra L, Hiendlmayr B et al .Thyrotoxic pericarditis: An underappreciatedphenomenon. International journal of  cardiology.2015;198:32-33.6. Clarke N, Banning A, Gwilt D et al. Pericardialdisease associated with Grave’s thyrotoxicosis.Qjm. 2002; 95(3):188-189.7. Nagata K, Nakayama Y, Higaki K  et al .Reactivation of persistent Epstein-Barr virus(EBV) causes secretion of thyrotropin receptorantibodies (TRAbs) in EBV-infected Blymphocytes with TRAbs on their surface.Autoimmunity. 2015; 48(5):328-335.8. Nagata K, Kumata K, Nakayama Y et al. Epstein-Barr Virus Lytic Reactivation Activates B CellsPolyclonally and Induces Activation-InducedCytidine Deaminase Expression: A MechanismUnderlying Autoimmunity and Its Contributionto Graves’ Disease. Viral Immunol. 2017; 30(3):240-249.9. Nagata K, Higaki K, Nakayama Y et al. Presenceof Epstein-Barr virus-infected B lymphocytes withthyrotropin receptor antibodies on their surfacein Graves’ disease patients and in healthyindividuals. Autoimmunity. 2014; 47(3):193-200.10. Nagata K, Fukata S, Kanai K et al. The influenceof Epstein-Barr virus reactivation in patients withGraves’ disease. Viral Immunol. 2011;24(2):143-149.11. Chhabra L, Khalid N, Spodick DH. [Letter onthe article “Pericardial effusion: an unknownexpression of Graves’ disease”]. Presse Med. 2014;43 (12 Pt 1):1407.12. Colakovski H, Lorber DL. Propylthiouracil-induced perinuclear-staining antineutrophilcytoplasmic autoantibody-positive vasculitis inconjunction with pericarditis. Endocrine Practice.2001; 7(1):37-39.

Pericardial effusion in a patient with hyperthyroidism: A case report

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Pericardial effusion in a patient with hyperthyroidism: A case report

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