Graves' Disease — a Rare Cause of Acute Myopericarditis?

1Mercy Catholic Medical Center, Darby, PA
2Mercy Catholic Medical Center, Darby, PA
3Mercy Catholic Medical Center, Darby, PA
4Mercy Catholic Medical Center, Darby, PA

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 388

Case Presentation:

This is the case of a 26‐year‐old woman who presented to the ED with complaints of sudden‐onset sharp substernal chest pain radiating to her back and neck for 1 day. The pain was worse with deep inspiration, supine position and alleviated with leaning forward. Review of symptoms was notable for lethargy and weight loss of 35–40 pounds. Vitals in ED were remarkable for sinus tachycardia with heart rate of 110/minute. Physical examination revealed diffusely enlarged thyroid gland and mild tremors of her hand. Her EKG showed sinus tachycardia with diffuse ST segment elevation in lead V2‐V6, I, II, III, aVF with PR depression in lead I, II, aVF, V3–V5. Chest x‐ray showed bilateral hilar prominence. CT chest showed bilateral peribronchial and interstitial thickening and faint ground‐glass infiltrates at base. Lab studies were remarkable for serum potassium of 3.2 mmol/L, CBC and LFT were normal. Thyroid studies showed a suppressed thyroid‐stimulating hormone (TSH) of 0.03 mIU/mL (0.27–4.62 mIU/mL), free T4 5.2 ng/dL (0.8–1.41 ng/dL), free T3 15 pg/mL (2.15–3.95 pg/mL), total T4 24.5 μg/dL (4.7–11.2 μg/dL), and total T3 509 ng/dL (80–200 ng/dL). Thyroid‐stimulating immunoglobulin and microsomal antibody were positive. Rheumatoid factor and ANA were negative. Ultrasound of her thyroid revealed diffusely heterogeneous gland. Cardiac biomarkers were elevated the day after the admission with values of troponin T 0.61, CK MB 34.7, and CK 208. Transthoracic echocardiogram revealed normal LV function with no regional wall motion abnormalities and no pericardial effusion. In view of the above findings, concurrent diagnosis of Graves' thyrotoxicosis and acute myopericarditis was made. The patient was started on methimazole, metoprolol, ibuprofen, and aspirin, and she became pain free on the second day of admission. Cardiac biomarkers trended down along with resolution of ST‐segment elevation. She was discharged home on the fourth day of admission.

Discussion:

The term myopericarditis is primarily a pericarditic syndrome. The causes of acute myopericarditis and pericarditis are the same. In the majority of cases, etiology is not found and such cases are presumed to have viral or auto immune etiology. Cardiac abnormalities that may be prominent in Graves' disease include sinus tachycardia, atrial fibrillation, and exacerbation of coronary artery disease or heart failure. Acute myopericarditis is rarely reported. The association of Graves' disease and myopericarditis in this patient is interesting. There have been four case reports of acute pericarditis and Graves' disease. Clarke et al. suggested that pericardial disease may be a rare unrecognized complication of Graves' thyrotoxicosis and may have a similar etiology to pretibial myxedema or ophthalmopathy.

Conclusions:

In conclusion, before classifying myopericarditis as idiopathic, one should rule out other uncommon etiologies like Graves' disease.

To cite this abstract:

Somasundaram A, Hunn R, Ruby E, Syeed M. Graves' Disease — a Rare Cause of Acute Myopericarditis?. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 388. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/graves-disease-a-rare-cause-of-acute-myopericarditis/. Accessed November 12, 2019.

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