Endocrine Abstracts

Introduction: Graves’ disease (GD) is associated with a number of cardiovascular complications, including rhythm disturbances, mitral valve prolapse, pulmonary hypertension and heart failure. Pericardial effusion in the context of GD has only been reported in a small number of cases.

Case: A 59-year-old gentleman presented with a 3-day history of dyspnoea and pleuritic chest pain. He had a previous history of GD 8 months ago, pulmonary embolism (PE), asthma, hypertension, obesity and was established on warfarin, following a second episode of PE, 4 weeks prior to this clinical event. Clinical examination revealed tachypnoea, tachycardia, raised JVP and bibasal crackles. Echocardiography showed a 2.9 cm pericardial effusion, compromising the right ventricular filling. 10 days prior to this admission, a previously echocardiogram had shown a smaller size pericardial effusion. TFTs showed suppressed TSH, elevated free T₄ at 34.7 pmol/l (reference range 9.2–21 pmol/l) and positive TSH receptor antibodies, compatible with relapsed GD. Other laboratory investigations showed acute kidney injury (eGFR 38 ml/min per 1.73 m²) and elevated INR at 17.2, which was pharmacologically reversed. Interestingly, 10 days prior to admission the patient had normal renal function. Analysis of the pericardial fluid showed inflammatory cells. Microbiology and cytology investigations were unremarkable. A full body CT scan did not show evidence of neoplastic process. The patient was stabilised following pericardiocentesis and was commenced on Carbimazole 40 mg daily.

Conclusions: This is an unusual presentation of GD. The patient was investigated extensively, but no alternative cause for pericardial effusion was found. The presence of inflammatory cells in the fluid, suggests an inflammatory pericarditis. GD could have also been implicated in the pathogenesis of the patient’s recent PE, given the thrombogenic tendency that hyperthyroidism is associated with. We therefore recommend that TFTs should be undertaken in patients presenting with unexplained pericardial effusion and equally patients with GD presenting with dyspnoea should undergo echocardiography.