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Raho EM, Antonioni A, Cotta Ramusino N, Jubea D, Gragnaniello D, Franceschetti P, Penitenti F, Daniele A, Zatelli MC, Naccarato M, Traluci I, Pugliatti M, Padroni M. Cerebral Venous Thrombosis during Thyrotoxicosis: Case Report and Literature Update. J Pers Med 2023; 13:1557. [PMID: 38003871 PMCID: PMC10672691 DOI: 10.3390/jpm13111557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare cause of stroke, particularly in young adults. Several known thrombophilic conditions may lead to an increased CVT risk. Interestingly, few cases in the literature have reported an association between CVT and thyrotoxicosis. Here, we describe the case of a young woman with CVT and concomitant thyrotoxicosis, without any other known prothrombotic conditions. We also performed a literature review of CVT cases and hyperthyroidism, searching for all articles published in peer-reviewed journals. We identified 39 case reports/case series concerning patients with CVT associated with thyrotoxicosis, highlighting, in most cases, the association with additional known prothrombotic factors. We then discussed the possible mechanisms by which hyperthyroidism could underlie a pro-coagulative state resulting in CVT. Thyroid disease might be a more common prothrombotic risk factor than expected in determining CVT. However, in most cases, a coexistence of multiple risk factors was observed, suggesting a multifactorial genesis of the disorder. We hope that this work may alert clinicians to consider thyrotoxicosis as a potential risk factor for CVT, even in patients who apparently have no other pro-coagulative conditions.
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Affiliation(s)
- Emanuela Maria Raho
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Annibale Antonioni
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
- Doctoral Program in Translational Neurosciences and Neurotechnologies, University of Ferrara, 44121 Ferrara, Italy
| | - Niccolò Cotta Ramusino
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Dina Jubea
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Daniela Gragnaniello
- Neurology Unit, Neurosciences and Rehabilitation Department, Ferrara University Hospital, 44124 Ferrara, Italy
| | - Paola Franceschetti
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Francesco Penitenti
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Andrea Daniele
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | | | - Ilaria Traluci
- Neuroradiology Unit, Ferrara University Hospital, 44124 Ferrara, Italy
| | - Maura Pugliatti
- Unit of Clinical Neurology, Neurosciences and Rehabilitation Department, University of Ferrara, 44121 Ferrara, Italy; (E.M.R.); (A.A.)
| | - Marina Padroni
- Neurology Unit, Neurosciences and Rehabilitation Department, Ferrara University Hospital, 44124 Ferrara, Italy
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Alsaidan A, Alruwiali F. Association between hyperthyroidism and thromboembolism: A retrospective observational study. Ann Afr Med 2023; 22:183-188. [PMID: 37026199 DOI: 10.4103/aam.aam_105_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Background Thyroid gland diseases are a common health problem worldwide. Increase of thyroid gland hormones can cause numerous conditions that range from mild cases to life-threatening diseases. Hyperthyroidism is not a common risk factor for venous thrombosis (VT), many studies found a relation between hyperthyroidism and thromboembolism. Objectives We sought to detect any changes in thyroid-stimulating hormone (TSH), and free T4 value associated with the occurrence of Deep vein thrombosis (DVT), pulmonary embolism (PE), and cerebral VT. Methodology An observational retrospective review of outpatients' records in King Abdulaziz Medical City in Riyadh from January 2018 to March 2020 includes all patients with hyperthyroidism, patients who are bedridden, recent surgeries, and those on oral contraceptives pills or on anticoagulants were excluded from the study. All symptomatic VT cases are objectively confirmed. Results Three hundred patients were recognized, of whom most were female (80%), whereas (20%) were male, mean age in identified patients was (42.3 ± 14.5 years; range, 18-80 years). Of all patients, 3 (1%) patients had DVTs, equally 3 (1%) patients had PE, and 2 (0.7%) patients had cerebral embolism. TSH level has a significant association with the overall risk of DVT, PE, and cerebral embolism. In the FT4 level, there was a significant association with the risk of DVT and PE but not with cerebral embolism. Conclusions The literature indicates a significantly associated between the development of VT and hyperthyroidism. Furthermore, the data support that hyperthyroidism is considered an additional risk factor for VT.
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Davis PJ, Mousa SA, Schechter GP. New Interfaces of Thyroid Hormone Actions With Blood Coagulation and Thrombosis. Clin Appl Thromb Hemost 2018; 24:1014-1019. [PMID: 29742907 PMCID: PMC6714741 DOI: 10.1177/1076029618774150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Substantial clinical evidence indicates hyperthyroidism enhances coagulation and increases the risk of thrombosis. In vitro and clinical evidence implicate multiple mechanisms for this risk. Genomic actions of thyroid hormone as 3,5,3′-triiodo-L-thyronine (T3) via a nuclear thyroid hormone receptor have been implicated, but recent evidence shows that nongenomic mechanisms initiated at the receptor for L-thyroxine (T4) on platelet integrin αvβ3 are prothrombotic. The T4-initiated mechanisms involve platelet activation and, in addition, cellular production of cytokines and chemokines such as CX3CL1 with procoagulatory activities. These procoagulant actions of T4 are particulary of note because within cells T4 is not seen to be functional, but to be only a prohormone for T3. Finally, it is also possible that thyroid hormone stimulates platelet-endothelial cell interaction involved in local thrombus generation. In this brief review, we survey mechanisms by which thyroid hormone is involved in coagulation and platelet functions. It is suggested that the threshold should be lowered for considering the possibility that clinically significant clotting may complicate hyperthyroidism. The value of routine measurement of partial thromboplastin time or circulating D-dimer in patients with hyperthyroid or in patients treated with thyrotropin-suppressing dosage of T4 requires clinical testing.
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Affiliation(s)
- Paul J Davis
- 1 Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA.,2 Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Shaker A Mousa
- 1 Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA
| | - Geraldine P Schechter
- 3 Hematology Section, Medical Service, Washington Veterans Affairs Medical Center, Washington, DC, USA.,4 Department of Medicine, George Washington University, Washington, DC, USA
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Elbers LPB, Fliers E, Cannegieter SC. The influence of thyroid function on the coagulation system and its clinical consequences. J Thromb Haemost 2018; 16:634-645. [PMID: 29573126 DOI: 10.1111/jth.13970] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 11/29/2022]
Abstract
Several studies indicate that low plasma levels of thyroid hormone shift the hemostatic system towards a hypocoagulable and hyperfibrinolytic state, whereas high levels of thyroid hormone lead to more coagulation and less fibrinolysis. Low levels of thyroid hormone thereby seem to lead to an increased bleeding risk, whereas high levels, by contrast, increase the risk of venous thromboembolism. Hypothyroidism leads to a higher incidence of acquired von Willebrand's syndrome and with increasing levels of free thyroxine, levels of fibrinogen, factor VIII and von Willebrand factor, amongst others, increase gradually, to the extent that they may lead to symptomatic venous thromboembolism in patients with hyperthyroidism. Here, we discuss the literature on the effect of thyroid hormone on the hemostatic system and the associated risk of bleeding and venous thromboembolism. Patients with hypothyroidism are at increased risk of developing bleeding complications, which could be relevant in patients undergoing invasive procedures. Furthermore, physicians should be aware of the possibility of hyperthyroidism as an underlying risk factor for venous thromboembolism, especially in unexplained cases. Clinical studies are needed to further investigate the significance for general practice of these findings. Besides the effects of hyperthyroidism on venous thromboembolism, its effects on embolism secondary to atrial fibrillation are described.
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Affiliation(s)
- L P B Elbers
- Department of Internal Medicine, MC Slotervaart, Amsterdam, the Netherlands
| | - E Fliers
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Fu FW, Rao J, Zheng YY, Song L, Chen W, Zhou QH, Yang JG, Ke JQ, Zheng GQ. Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis: A case report and review of literature. Medicine (Baltimore) 2017; 96:e7374. [PMID: 28816935 PMCID: PMC5571672 DOI: 10.1097/md.0000000000007374] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is characterized by a pattern of extravasated blood restricted to the perimesencephalic cisterns, normal angiographic findings, and an excellent prognosis with an uneventful course and low risks of complication. The precise etiology of bleeding in patients with PNSAH has not yet been established. The most common hypothesis is that PNSAH is venous in origin. Intracranial venous hypertension has been considered as the pivotal factor in the pathogenesis of PNSAH. The underlying venous pathology such as straight sinus stenosis, jugular vein occlusion may contribute to PNSAH. We describe a patient in whom transverse sinus thrombosis preceded intracranial venous hypertension and PNSAH. These findings supported that the source of the subarachnoid hemorrhage is venous in origin. PATIENT CONCERNS AND DIAGNOSES A 45-year-old right-handed man was admitted to the hospital with a sudden onset of severe headache associated with nausea, vomiting, and mild photophobia for 6 hours. The patient was fully conscious and totally alert. An emergency brain computed tomography (CT) revealed an acute subarachnoid hemorrhage restricted to the perimesencephalic cisterns. CT angiography revealed no evidence of an intracranial aneurysm or underlying vascular malformation. Digital subtraction angiography of arterial and capillary phases confirmed the CT angiographic findings. Assessment of the venous phase demonstrated right transverse sinus thrombosis. Magnetic resonance imaging confirmed the diagnosis of cerebral venous sinus thrombosis (CVST). Lumbar puncture revealed an opening pressure of 360 mmH2O, suggestive of intracranial venous hypertension. Grave disease was diagnosed by endocrinological investigation. INTERVENTIONS Low-molecular-weight heparin, followed by oral warfarin, was initiated immediately as the treatment for cerebral venous sinus thrombosis and PNSAH. OUTCOMES The patient discharged without any neurologic defect after 3 weeks of hospital stay. MR venography revealed recanalization of right transverse sinus at the 6-month follow-up. No clinical or neuroimaging evidence of relapse was detected at 12 months follow-up. LESSONS Hyperthyroidism may contribute to the development of CVST. The presence of acute transverse sinus thrombosis, as a cause of PNSAH, provides further support for the hypothesis that the source of PNSAH is venous in origin and intracranial venous hypertension plays a critical role in the pathogenesis of PNSAH.
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Affiliation(s)
| | - Jie Rao
- From the Department of Neurology, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, Zhejiang Province
| | | | - Liang Song
- From the Department of Neurology, Zhengzhou People's Hospital, Zhengzhou, Henan Province, China
| | - Wei Chen
- Department of Radiology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou
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Kim BR, Jung JH, Hahm JR, Jung J, Park HJ, Kim SK. A Case of Cerebral Venous Thrombosis in a Patient with Graves' Disease. KOSIN MEDICAL JOURNAL 2016. [DOI: 10.7180/kmj.2016.31.2.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Superior sagittal sinus thrombosis is an uncommon disease, and 25% of cases are considered to be idiopathic. Hypercoagulability, local bloodstream stasis, and vessel wall abnormalities may contribute to the development of this condition. The thyrotoxic phase of Graves' disease is associated with venous thrombosis caused by hypercoagulability, which is in turn induced by increased levels of homocysteine and factor VIII and decreased fibrinolytic activity. Here, we report the case of a 39-year-old male who presented with superior sagittal sinus thrombosis and concomitant hyperthyroidism.
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Elbers LPB, Kastelein JJP, Sjouke B. Thyroid Hormone Mimetics: the Past, Current Status and Future Challenges. Curr Atheroscler Rep 2016; 18:14. [PMID: 26886134 PMCID: PMC4757599 DOI: 10.1007/s11883-016-0564-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The association between thyroid hormone status and plasma levels of low-density lipoprotein cholesterol has raised the awareness for the development of thyroid hormone mimetics as lipid-lowering agents. The discovery of the two main types of thyroid hormone receptors (α and β) as well as the development of novel combinatorial chemistry providing organ specificity has drastically improved the selectivity of these compounds. In the past decades, several thyroid hormone mimetics have been investigated with the purpose of lowering low-density lipoprotein cholesterol levels. However, until now, none of the thyromimetics reached the stage of completing a phase III clinical trial without deleterious side effects. Here, we review the currently available literature on thyromimetics investigated for the treatment of dyslipidemia, their rise, their downfall and the challenges for the development of novel agents.
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Affiliation(s)
- L P B Elbers
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Internal Medicine, Medical Center Slotervaart, Amsterdam, The Netherlands
| | - J J P Kastelein
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - B Sjouke
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Kyriakakis N, Lynch J, Ajjan R, Murray RD. The effects of pituitary and thyroid disorders on haemostasis: potential clinical implications. Clin Endocrinol (Oxf) 2016; 84:473-84. [PMID: 25753252 DOI: 10.1111/cen.12767] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/09/2014] [Accepted: 03/03/2015] [Indexed: 12/22/2022]
Abstract
Disturbances of coagulation and fibrinolysis are usually multifactorial and growing evidence suggests that endocrinopathies modulate the haemostatic balance. The thrombotic alterations in endocrine disorders range from mild laboratory clotting abnormalities with little clinical significance to serious thrombotic and bleeding disorders directly related to hormonal disturbances. This literature review focuses on presenting the current data on the effects of thyroid and pituitary disorders on various parameters of the haemostatic system. With the exception of overt hypothyroidism which appears to cause a bleeding tendency, the rest of the endocrinopathies discussed in this review (subclinical hypothyroidism, hyperthyroidism, endogenous hypercortisolaemia, growth hormone deficiency, acromegaly, prolactinoma/hyperprolactinaemia and hypogonadotrophic hypogonadism) are associated with a hypercoagulable and hypofibrinolytic state, increasing the overall cardiovascular risk and thromboembolic potential in these patients. In most studies, the haemostatic abnormalities seen in endocrine disorders are usually reversible with successful treatment of the underlying condition and biochemical disease remission. High-quality studies on larger patient cohorts are needed to produce robust evidence on the effects of endocrine disorders and their therapeutic interventions on coagulation and fibrinolysis, as well as on the long-term mortality and morbidity outcomes in association with endocrine-related haemostatic imbalance. Given the rarity of some of the endocrine disorders, multicentre studies are required to achieve this target.
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Affiliation(s)
- Nikolaos Kyriakakis
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Julie Lynch
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ramzi Ajjan
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
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Elbers LPB, Moran C, Gerdes VE, van Zaane B, Meijers J, Endert E, Lyons G, Chatterjee VK, Bisschop PH, Fliers E. The Hypercoagulable state in Hyperthyroidism is mediated via the Thyroid Hormone β Receptor pathway. Eur J Endocrinol 2016; 174:EJE-15-1249. [PMID: 26961801 PMCID: PMC7613030 DOI: 10.1530/eje-15-1249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hyperthyroidism is associated with a hypercoagulable state, but the underlying mechanism is unknown. Patients with resistance to thyroid hormone (RTH) due to defective thyroid hormone receptor β (TRβ) exhibit elevated circulating thyroid hormones (TH) with refractoriness to TH action in TRβ-expressing tissues. We tested the hypothesis that the hypercoagulable state in hyperthyroidism is mediated via the TRβ. DESIGN We conducted a cross-sectional study from November 2013 to January 2015 in 3 hospitals in the Netherlands and the United Kingdom. METHODS Patients with RTH due to defective TRβ (n=18), patients with hyperthyroidism (n=16) and euthyroid subjects (n=18) were included. TH concentrations and markers of coagulation and fibrinolysis were measured. Data are expressed as median [interquartile range]. RESULTS Free thyroxine (FT4) levels were slightly higher in hyperthyroid patients than in RTH patients (53.9 [30.5-70.0] and 34.9 [28.4-42.2]pmol/l, respectively, P=0.042). Both groups had raised FT4 levels compared to euthyroid subjects (14.0 [13.0-15.8] pmol/l, P≤0.001). Levels of von Willebrand factor (VWF), factor (F) VIII, fibrinogen, and D-dimer were significantly higher in hyperthyroid patients than in RTH patients (VWF 231 [195-296] vs. 111 [82-140]%, FVIII 215 [192-228] vs. 145 [97-158]%, fibrinogen 3.6 [3.0-4.4] vs. 2.8 [2.5-3.2]g/L, D-dimer 0.41 [0.31-0.88] vs. 0.20 [0.17-0.26]mg/L, respectively, P≤0.001), while there were no differences between RTH patients and euthyroid controls. CONCLUSIONS Parameters of coagulation and fibrinolysis were elevated in hyperthyroid patients compared to patients with RTH due to defective TRβ, whereas these parameters were not different between euthyroid controls and RTH patients, despite elevated FT4 concentrations in RTH patients. This indicates that the procoagulant effects observed in hyperthyroidism are mediated via the TRβ.
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Affiliation(s)
- Laura P B Elbers
- L Elbers, Internal Medicine, Medical Center Slotervaart, Amsterdam, Netherlands
| | - Carla Moran
- C Moran, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Victor Ea Gerdes
- V Gerdes, Internal Medicine, Medical Center Slotervaart, Amsterdam, Netherlands
| | - Bregje van Zaane
- B van Zaane, Internal Medicine, Medical Center Slotervaart, Amsterdam, Netherlands
| | - Joost Meijers
- J Meijers, Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Erik Endert
- E Endert, Laboratory of Endocrinology and Radiochemistry, Department of Clinical Chemistry, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Greta Lyons
- G Lyons, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - V Krishna Chatterjee
- V Chatterjee, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Peter H Bisschop
- P Bisschop, Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Eric Fliers
- E Fliers, Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Angkananard T, Chonmaitree P, Petborom P. Unexpected causes of pulmonary hypertension in a previously healthy Thai rural man with right-sided heart failure. AMERICAN JOURNAL OF CASE REPORTS 2014; 15:180-4. [PMID: 24808937 PMCID: PMC4011672 DOI: 10.12659/ajcr.890340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 01/23/2014] [Indexed: 11/09/2022]
Abstract
Male, 52 Final Diagnosis: Pulmonary hypertension Symptoms: Diarrhea • dyspnea • jaundice Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic
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Affiliation(s)
- Teeranan Angkananard
- Division of Cardiology, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Piyanant Chonmaitree
- Division of Gastroenterology, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Pichaya Petborom
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand
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