PERICARDIAL EFFUSION IN A PATIENT WITH HYPERTHYROIDISM: A CASE REPORT

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M.O. Fabowale¹ , O.S. Ogah^1,2,3 , A.M. Kehinde¹ , F.I. Olusola¹ , I.J. Okafor¹ , T.A. Bakare¹ , V. Obasuyi¹ , O.O. Orimolade¹ , A. Aje¹ , and A. Adebiyi^1,2

1. 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.

Abstract

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 medications and steroid therapy. We recommend a high index of suspicion of this association in patients with hyperthyroidism and/or Graves’ disease.

Keywords: Thyroid disease, Hyperthyroidism, Pericarditis, Pericardial effusion

Introduction

Hyperthyroidism is a syndrome associated with excess thyroid hormone production. Patients typically present with irritability, unintentional weight loss, heat intolerance, malaise, diaphoresis, gastrointestinal hypermotility and diarrhoea. Cardiovascular complications of hyperthyroidism include high or normal output heart failure, arrhythmias and tachycardia-associated cardiomyopathy.^{1, 2}

Pericardial effusion is rare in hyperthyroidism when compared to hypothyroidism. Autoimmune pericarditis has been reported in Graves’ disease.³

Herein, we present the case of a 28-year-old woman who was admitted with features of hyperthyroidism and pericardial effusion, the effusion resolved following treatment of hyperthyroidism.

CASE REPORT 

A 28-year-old lady presented to the Medical Outpatient Clinic of our hospital on account of a three-months history of recurrent palpitations, easy fatigability and exertional dyspnea. Palpitations occur most times of the day but worse at rest. There was history diaphoresis but no chest pain or pressure like sensations on the chest. No history of headaches, blurring of vision, feeling of impending doom or syncopal attacks. She however reported malaise, easy fatigability and dyspnoea on exertion which later progressed to dyspnoea even at rest. She denied any report of cough, paroxysmal nocturnal dyspnea, orthopnoea or recurrent pedal oedema. She had no preceding symptoms of upper respiratory tract infection or background anxiety disorder. She also has unintentional weight loss, early satiety and loss of appetite. There was associated recurrent effortless postprandial vomiting with vague abdominal pain and hyperdefecation. She reported tremors, heat intolerance and scanty menses. She did not have dysphagia or change in her voice.

At presentation, she was restless, diaphoretic and mildly dehydrated. She was not febrile, not pale, anicteric, not cyanosed and had no digital clubbing. She had no significant peripheral lymphadenopathy and no pedal edema. There was an anterior neck swelling measuring 4 x 6cm but more to the right side. The swelling was firm in consistency with irregular edges, non-tender and no differential warmth. There was no exophthalmos or lid lag. There were fine tremors. She was dyspneic, respiratory rate was 36 breaths per minutes, trachea was central and breath sound were vesicular bilaterally. Her pulse was 112/min and regular, BP 120/70mmHg, JVP was not elevated and apex beat was difficult to localize. First and Second Hearts sounds were heard with pericardial friction rub. She was conscious, alert, oriented in time place and person, pupils 3mm equal, round, bilaterally reactive to light, no cranial nerve deficit, no sign of meningeal irritation, normal muscle bulk, tone and reflexes.

She was admitted for evaluation. Imaging studies revealed a relatively normal chest with a normal mediastinal contour. Table 1 shows the investigation results. The ECG (Figure 1) showed sinus tachycardia. Echocardiography (Figure 2) revealed a pericardial effusion over the left ventricle with fibrinous strands in the pericardial cavity.

She was commenced on oral medications which includes prednisolone 40mg daily, propranolol 20mg b.d., rabeprazole 20mg daily and carbimazole 15mg b.d. She had made significant improvement on follow up clinic appointments.