Sanguineous Pericardial Effusion and Cardiac Tamponade in the Setting of Graves' Disease: Report of a Case and Review of Previously Reported Cases

Symptomatic Pericardial Effusion Associated With Graves' Disease in a Pediatric Patient

Pericarditis is a well-known complication of hypothyroidism. Although pericarditis and pericardial effusions have been reported as rare complications of hyperthyroidism in adults, they are rarely reported in the pediatric population. In this case report, we describe a 12-year-old, previously healthy girl with nighttime chest pain, dyspnea, tachycardia, and abnormal thyroid function studies consistent with hyperthyroidism who was found to have pericarditis and pericardial effusion requiring pericardiocentesis.

Data Analysis and Systematic Scoping Review on the Pathogenesis and Modalities of Treatment of Thyroid Storm Complicated with Myocardial Involvement and Shock

Thyroid storm (TS) is a rare and fatal endocrine emergency that occurs due to undiagnosed and inadequately treated hyperthyroidism after stressful conditions in patients with thyroid disorders. The objective of this systematic scoping review was to better understand the pathophysiology of TS and its complications, in terms of myocardial affection, tachyarrhythmia, and cardiogenic shock. In addition, we explored the pharmacological, mechanical, and surgical treatments for TS. We also evaluated the outcomes of TS according to sex and cardiac involvement. Additionally, analytical analysis was performed on the selected data. A literature review of peer-reviewed journals was carried out thoroughly using medical terms, MeSH on PubMed, Google Scholar, and combinations such as thyrotoxicosis-induced cardiomyopathy, thyroid storm, cardiogenic shock, myocardial infarction, endocrine emergency, Burch-Wartofsky score, extracorporeal circulatory support, and thyroidectomy. A total of 231 papers were eligible (2 retrospective studies, 5 case series, and 224 case reports) with a total of 256 TS patients with cardiac involvement between April 2003 and August 2023. All age groups, sexes, patients with TS-induced cardiomyopathy, non-atherosclerotic myocardial infarction, tachyarrhythmia, heart failure, shock, and different forms of treatment were discussed. Non-English language articles, cases without cardiac involvement, and cases in which treatment modalities were not specified were excluded. Female sex was predominant, with 154 female and 102 male patients. Approximately 82% of patients received beta-blockers (BBs), 16.3% were placed on extracorporeal membrane oxygenation (ECMO) support, 16.3% received therapeutic plasma exchange (TPE), and 13.8% underwent continuous renal replacement therapy (CRRT), continuous venovenous hemofiltration (CVVHD), or dialysis. Overall, 18 females and 16 males died. BB-induced circulatory collapse, acute renal failure, CRRT, and ventricular fibrillation were significantly associated with mortality. Awareness of TS and not only thyrotoxicosis is vital for timely and appropriate treatment. The early diagnosis and management of TS in cardiac settings, including pharmacological, mechanical, and surgical modalities, can save high-risk patients. Sex matters in the presentation, treatment, and mortality of this population. However, further large-scale, and well-designed studies are required.

Iodinated Contrast-Induced Thyroid Storm With Concomitant Cardiac Tamponade: A Case Report

A thyroid storm is a rare but life-threatening condition caused by the exaggeration of the clinical manifestations of thyrotoxicosis. The symptoms of thyroid storms are non-specific in nature, making the Burch Wartofsky Point Scale (BWPS) a valuable resource in the diagnosis of thyroid storms. Though not part of the BWPS scoring criteria, literature reviews have shown an increasing number of reports of pericardial effusion secondary to thyrotoxicosis. Pericardial effusion is a well-known sequela of hypothyroidism that, in severe cases, can cause cardiac tamponade. With increasing reports, clinicians should be aware that pericardial effusions can develop secondary to both underactive and overactive thyroid states. We present a case of iodine contrast-induced Jod-Basedow in a 29-year-old with a prior history of Graves disease with concomitant pericardial effusion requiring thyroidectomy.

Significant cardiac disease complicating Graves' disease in previously healthy young adults

SUMMARY

Graves' disease is associated with tachydysrythmia, cardiac ischaemia and cardiomyopathy - all uncommon in young adults without previous cardiac disease. We present three young individuals who developed cardiac complications after periods of uncontrolled Graves' disease. Subject 1: A 34-year-old female had severe thyrotoxic symptoms for weeks. Investigations showed fT4: 98.4 (11-25 pmol/L), fT3: 46.9 (3.1-6.8 pmol/L), TSH <0.01 (0.27-4.2 mU/L) and thyrotrophin receptor antibody (TRAb): 34.8 (<0.9 U//l). She had appropriate treatment but several weeks later she became breathless despite improving thyroid function. Echocardiography showed a pericardial effusion of 2.9 cm. She responded well to steroids and NSAIDs but developed active severe Graves' orbitopathy after early total thyroidectomy. Subject 2: A 28-year-old male developed thyrotoxic symptoms (fT4: 38 pmol/L, fT3: 13.9 pmol/L, TSH <0.01 (for over 6 months) and TRAb: 9.3 U/L). One month after starting carbimazole, he developed acute heart failure (HF) due to severe dilated cardiomyopathy - EF 10-15%. He partially recovered after treatment - EF 28% and had early radioiodine treatment. Subject 3: A 42-year-old woman who had been thyrotoxic for several months (fT4: 54.3; fT3 >46.1; TSH <0.01; TRAb: 4.5) developed atrial fibrillation (AF) and heart failure. Echocardiography showed cardiomegaly - EF 29%. She maintains sinus rhythm following early total thyroidectomy (EF 50%). Significant cardiac complications may occur in previously fit young adults, who have had uncontrolled Graves' disease for weeks to months. Cardiac function recovers in the majority, but early definitive treatment should be discussed to avoid Graves' disease relapse and further cardiac decompensation.

LEARNING POINTS

Cardiac complications of Graves' disease are uncommon in young adults without previous cardiac disease. These complications may however occur if Graves' disease had been poorly controlled for several weeks or months prior to presentation. Persistent symptoms after adequate control should alert clinicians to the possibility of cardiac disease. Specific treatment of Graves' disease and appropriate cardiac intervention results in complete recovery in the majority and carries a good prognosis. Early definitive treatment should be offered to them to prevent cardiac decompensation at times of further relapse.