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Tang M, Fteiha B, Meng S. Unusual Management of a Rare Case of Methimazole-Resistant Graves Disease. JCEM CASE REPORTS 2025; 3:luae235. [PMID: 39703535 PMCID: PMC11656567 DOI: 10.1210/jcemcr/luae235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Indexed: 12/21/2024]
Abstract
As the leading cause of hyperthyroidism, Graves disease (GD) does not often present with its classical triad of pretibial myxedema, goiter, and exophthalmos but instead is often recognized by various manifestations such as tachycardia, weight loss, jaundice, or dermatopathy and requires utmost clinical vigilance. Three treatment modalities for GD exist as antithyroid drugs (ATDs), radioactive iodine (RAI), and surgery, but each bears its own serious side effects. Furthermore, there have been several reports in the literature about ATD resistance that can complicate management. We describe a rare complex case of methimazole (MMI)-resistant GD in a 58-year-old woman with multiple comorbidities including heart failure, atrial fibrillation, liver cirrhosis, and hypertension. She presented with an initial complaint of diffuse swelling and was found to have severe thyrotoxicosis. Despite high doses of MMI, her thyroid function remained significantly elevated. Thyroid uptake and scan while on MMI showed high radioactive iodine uptake. After receiving RAI therapy, her thyroid function and bilirubin improved markedly, liver enzymes remained stable, and anasarca responded to diuretics. This case highlights the challenges in managing resistant GD and emphasizes the necessity of personalized treatment plans.
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Affiliation(s)
- Michael Tang
- Baylor University Medical Center, Dallas, TX 75246, USA
| | - Bashar Fteiha
- Baylor University Medical Center, Dallas, TX 75246, USA
| | - Shumei Meng
- Baylor University Medical Center, Dallas, TX 75246, USA
- Texas A&M School of Medicine, Bryan, TX 77807, USA
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Campos F, Sharma A, Patel B, Papadopoulou D, Comninos AN, Abbara A. Liver Dysfunction in a Patient with Graves' Disease. J Clin Med 2024; 13:6968. [PMID: 39598112 PMCID: PMC11595224 DOI: 10.3390/jcm13226968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 10/23/2024] [Accepted: 11/15/2024] [Indexed: 11/29/2024] Open
Abstract
Liver dysfunction can occur in patients presenting with thyrotoxicosis, due to several different aetiologies. A 42-year-old man had mild liver dysfunction on presentation with hyperthyroidism due to Graves' disease (GD): ALT 65 (0-45 IU/L), fT4 41.2 (9-23 pmol/L), fT3 > 30.7 (2.4-6 pmol/L), and TSH < 0.01 (0.3-4.2 mIU/L). His liver dysfunction worsened following the initiation of the antithyroid drug (ATD) carbimazole (CBZ), with ALT reaching a zenith of 263 IU/L at 8 weeks following presentation. Consequently, CBZ was stopped, and he was managed with urgent radioiodine therapy. His liver function tests (LFTs) improved within 1 week of stopping carbimazole (ALT 74 IU/L). Thionamide-induced liver dysfunction is more typically associated with a 'cholestatic' pattern, although he had a 'hepatitic' pattern of liver dysfunction. The risk of liver dysfunction in GD increases with older age and higher titres of thyroid-stimulating hormone receptor antibody (TRAb). This review of the literature seeks to explore the possible causes of liver dysfunction in a patient presenting with hyperthyroidism, including thyrotoxicosis-induced liver dysfunction, ATD-related liver dysfunction, and the exacerbation of underlying unrelated liver disease.
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Affiliation(s)
- Filipa Campos
- Section of Endocrinology and Investigative Medicine, Imperial College London, London W12 ONN, UK
| | - Angelica Sharma
- Section of Endocrinology and Investigative Medicine, Imperial College London, London W12 ONN, UK
| | - Bijal Patel
- Section of Endocrinology and Investigative Medicine, Imperial College London, London W12 ONN, UK
| | - Deborah Papadopoulou
- Section of Endocrinology and Investigative Medicine, Imperial College London, London W12 ONN, UK
- Division of Endocrinology, Imperial College Healthcare NHS Trust, London W12 ONN, UK
| | - Alexander N. Comninos
- Section of Endocrinology and Investigative Medicine, Imperial College London, London W12 ONN, UK
- Division of Endocrinology, Imperial College Healthcare NHS Trust, London W12 ONN, UK
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, London W12 ONN, UK
- Division of Endocrinology, Imperial College Healthcare NHS Trust, London W12 ONN, UK
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3
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Li C, Wang KL, Hu JH, Su HB. Clinical manifestations and early effectiveness of methimazole in patients with graves' hyperthyroidism-related severe hepatic dysfunction. Scand J Gastroenterol 2023; 58:1514-1522. [PMID: 37545358 DOI: 10.1080/00365521.2023.2244107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/29/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Graves' hyperthyroidism (GH) is often accompanied by mild to moderate liver injury, but severe hepatic dysfunction (SHD) is relatively rare. Whether patients with GH-related SHD can be treated with methimazole (MMI) remains controversial. This study aimed to determine the clinical characteristics and to evaluate the role of low-dose MMI for such patients. METHODS 33 patients with GH-related SHD were selected for this retrospective study in the Fifth Medical Center of Chinese PLA General Hospital from January 2017 to July 2022. The clinical manifestations, therapeutic responses, and effectiveness of MMI were evaluated. RESULTS Systemic jaundice (100.0%), yellow urine (100.0%), fatigue (87.9%), and goiter (66.7%) were the main symptoms. Total bilirubin (TBIL) had no linear correlation with free triiodothyronine (FT3) (r = -0.023, p = .899), free thyroxine (FT4) (r = 0.111, p = .540), T3 (r = -0.144, p = .425), and T4 (r = 0.037, p = .837). On the 14th day after admission, FT3, FT4, T3, T4, TBIL, direct bilirubin (DBIL), alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), γ-glutamyltransferase (GGT), and international normalized ratio (INR) decreased compared with the baseline (p < .05). The decrease rates of FT3, FT4, T3, T4, TBIL, and DBIL in the MMI group were higher than those in the non-MMI group (p < .05). The improvement rate of the MMI group (77.8%) was higher than that of the non-MMI group (9.5%, p = .001). MMI treatment is an independent predictor affecting the early improvement of patients (OR = 0.022, p = .010). CONCLUSIONS The main clinical manifestations of patients with GH-related SHD were symptoms related to liver disease. Low-dose MMI was safe and effective for them.
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Affiliation(s)
- Chen Li
- Department of Hepatology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Clinical Medical School, Peking University, Beijing, China
| | - Kai-Li Wang
- Department of Hepatology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Clinical Medical School, Peking University, Beijing, China
| | - Jin-Hua Hu
- Department of Hepatology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Clinical Medical School, Peking University, Beijing, China
| | - Hai-Bin Su
- Department of Hepatology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Clinical Medical School, Peking University, Beijing, China
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Al‐Mashdali AF, Alfatih M, Umer W, Eldeeb Y. Thyrotoxic periodic paralysis as the first presentation of Graves' disease: A case report. Clin Case Rep 2023; 11:e7188. [PMID: 37197293 PMCID: PMC10183649 DOI: 10.1002/ccr3.7188] [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: 08/22/2022] [Revised: 03/16/2023] [Accepted: 03/24/2023] [Indexed: 05/19/2023] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare disease seen predominantly in men of Asian origin. It should be considered in the differential diagnosis of patients with acute onset of weakness, and it is reversible after the correction of serum potassium. TPP can rarely be the initial presentation of Graves' disease.
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Affiliation(s)
| | | | - Waseem Umer
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Yasser Eldeeb
- Department of Infectious DiseasesHamad Medical CorporationDohaQatar
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Ajwah I, Alshehri S, Alremthi F, Alahmari N. Rare Presentation of a Common Disease: Graves' Thyrotoxicosis Presented With Non-parathyroid Hypercalcemia and Jaundice. Cureus 2023; 15:e35206. [PMID: 36960248 PMCID: PMC10031658 DOI: 10.7759/cureus.35206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Graves' disease (GD) is an autoimmune thyroid disease, which is considered the most common cause of primary hyperthyroidism. GD usually manifests with symptoms such as tremors, palpitations, heat intolerance, weight loss, and specific signs on physical examination (proptosis and pretibial myxedema). However, systemic involvement is also recognized, for example, hepatic involvement in patients with GD may range from asymptomatic laboratory findings of liver function derangement (either transaminases elevations or intrahepatic cholestasis) up to hepatic failure. We describe a rare case of Graves' thyrotoxicosis presenting with severe cholestasis and non-parathyroid hormone-related hypercalcemia. An extensive evaluation for hepatobiliary causes of cholestasis, including hepatic biopsy, was entirely negative. The patient was successfully treated with methimazole with subsequent clinical and biochemical improvement.
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Affiliation(s)
- Ibrahim Ajwah
- Department of Endocrinology, Diabetes and Metabolism, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, SAU
- Department of Internal Medicine, King Salman Armed Forces Hospital, Ministry of Defense, Tabuk, SAU
| | - Sameerah Alshehri
- Department of Endocrinology, Diabetes and Metabolism, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, SAU
| | - Fahad Alremthi
- Department of Endocrinology, Diabetes and Metabolism, King Abdullah Hospital, Diabetes and Endocrine Center, Ministry of Health (MOH), Bisha, SAU
| | - Nasser Alahmari
- Department of Endocrinology, Diabetes and Metabolism, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, SAU
- Department of Internal Medicine, King Salman Armed Forces Hospital, Ministry of Defense, Tabuk, SAU
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Impact of Graves Disease on Ocular Surface and Corneal Epithelial Thickness in Patients With and Without Graves Orbitopathy. Cornea 2021; 41:443-449. [PMID: 34029245 DOI: 10.1097/ico.0000000000002753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/14/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Our aim was to assess ocular surface and tear film stability and corneal epithelial thickness (CET) in patients with Graves disease (GD) with and without Graves orbitopathy (GO). METHODS This study included healthy age-matched controls and patients with GD. Symptoms (Ocular Surface Disease Index questionnaire) and signs (schirmer test and tear breakup time test) of dry eye disease were determined, according to the International Dry Eye Workshop II criteria of DED. CET map was also assessed. RESULTS Twenty-four eyes were included in the control group, with a mean age of 41.00 ± 13.65 years, and 34 in the GD group, 18 with GO and 16 without GO, with a mean age of 44.44 ± 13.95 and 45.75 ± 10.59 years, respectively. All patients with GO had inactive disease (mean clinical activity score: 1.33 ± 0.69). Patients with GD had higher proportion of clinical diagnosis of dry eye disease (GO vs. GD without GO vs. controls: 77.77% vs. 75.00% vs. 4.17%), with higher Ocular Surface Disease Index (GO vs. GD without GO vs. controls: 15.44 vs. 15.06 vs. 9.88) and lower tear breakup time test (GO vs. GD without GO vs. controls: 6.33 s vs. 7.25 s vs. 11.63 s). Superior CET was lower in patients with GD (P < 0.05). No differences were found between patients with and without GO (P > 0.05). CONCLUSIONS GD negatively influenced ocular surface and CET, with a higher level of eye dryness and corneal thinning regardless of GO status, suggesting that subclinical chronic inflammation may play a role in the pathogenesis of tear film and ocular surface stability.
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Kandinata SG, Soelistijo SA, Amrita PNA. Graves' Disease Presenting as Autoimmune Hemolytic Anemia. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930705. [PMID: 33946094 PMCID: PMC8077400 DOI: 10.12659/ajcr.930705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Female, 29-year-old Final Diagnosis: Graves’ disease Symptoms: General malaise Medication:— Clinical Procedure: Laboratory checkup Specialty: Endocrinology and Metabolism • Hematology
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Affiliation(s)
- Stefanus Gunawan Kandinata
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital - Faculty of Medicine Airlangga University, Surabaya, Indonesia
| | - Soebagijo Adi Soelistijo
- Endocrinology, Metabolism, and Diabetes Unit, Department of Internal Medicine, Dr. Soetomo General Academic Hospital - Faculty of Medicine Airlangga University, Surabaya, Indonesia
| | - Putu Niken A Amrita
- Hematology and Medical Oncology Unit, Department of Internal Medicine, Dr. Soetomo General Academic Hospital - Faculty of Medicine Airlangga University, Surabaya, Indonesia
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Fattizzo B, Ferraresi M, Giannotta JA, Barcellini W. Secondary Hemophagocytic Lymphohistiocytosis and Autoimmune Cytopenias: Case Description and Review of the Literature. J Clin Med 2021; 10:870. [PMID: 33672504 PMCID: PMC7923749 DOI: 10.3390/jcm10040870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 12/25/2022] Open
Abstract
Hemophagocytic lymphohistocytosis (HLH) is a rare hyperinflammatory condition which may be primary or secondary to many diseases, including hematologic malignancies. Due to its life-threatening evolution, a timely diagnosis is paramount but challenging, since it relies on non-specific clinical and laboratory criteria. The latter are often altered in other diseases, including autoimmune cytopenias (AIC), which in turn can be secondary to infections, systemic autoimmune or lymphoproliferative disorders. In the present article, we describe two patients presenting at the emergency department with acute AICs subsequently diagnosed as HLH with underlying diffuse large B cell lymphoma. We discuss the diagnostic challenges in the differential diagnosis of acute cytopenias in the internal medicine setting, providing a literature review of secondary HLH and AIC.
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Affiliation(s)
- Bruno Fattizzo
- Oncohematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (W.B.)
- Department of Oncology and Oncohematology, University of Milan, 20122 Milan, Italy
| | - Marta Ferraresi
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Internal Medicine, University of Milan, 20122 Milan, Italy
| | - Juri Alessandro Giannotta
- Oncohematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (W.B.)
| | - Wilma Barcellini
- Oncohematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (W.B.)
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9
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Rodriguez V, Gonzales KM, Iqbal AM, Arbelo-Ramos N, Wyatt KD, Lteif AN, Castro MR. PANCYTOPENIA SECONDARY TO AUTOIMMUNE VITAMIN B 12 DEFICIENCY IN GRAVES DISEASE. AACE Clin Case Rep 2020; 6:e282-e285. [PMID: 33244485 DOI: 10.4158/accr-2020-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/26/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To describe a case of Graves disease (GD) and coexistent pancytopenia associated with autoimmune vitamin B12 deficiency. While thyrotoxicosis and antithyroid drugs can cause pancytopenia, other autoimmune conditions such as vitamin B12 deficiency can occur, leading to severe anemia and pancytopenia. Methods A 19-year-old female with GD treated with methimazole presented with thyrotoxicosis and evidence of pancytopenia. Diagnostic studies included a complete blood cell count, peripheral blood smears, thyroid function tests, and a bone marrow biopsy. Results White blood cells were 2.4 × 109 cells/L (reference range [RR] is 3.4 to 9.6 × 109 cells/L), hemoglobin was 7.9 g/dL (RR is 11.6 to 15.0 g/dL), neutrophil count was 1.2 × 109 cells/L, and platelets were 84 × 109 cells/L (RR is 157 to 371 × 109 cells/L). Thyroid-stimulating hormone was <0.01 mIU/L (RR is 0.50 to 4.30 mIU/L), free thyroxine was 3.7 ng/dL (RR is 1.0 to 1.6 ng/dL), and total triiodothyronine was 221 ng/dL (RR is 91 to 218 ng/dL). Due to suspicion for drug-induced pancytopenia, methimazole was discontinued. Three days later, she was hospitalized for a syncopal episode with a further decline in hemoglobin to 6.7 g/dL, neutrophils to 0.68 × 109 cells/L, and platelets to 69 × 109 cells/L. Bone marrow biopsy findings showing marrow hypercellularity and hypersegmented neutrophils suggested vitamin B12 deficiency. Vitamin B12 was <70 ng/L (RR is 180 to 914 ng/L). Intramuscular vitamin B12 injections were initiated, and pancytopenia resolved within 1 month. Conclusion Although rarely described in the literature, autoimmune vitamin B12 deficiency can be missed as an underlying etiology for pancytopenia in patients with GD. The clinical picture can be further confounded when these patients are treated with antithyroid drugs known to cause bone marrow suppression.
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10
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Barcellini W, Giannotta J, Fattizzo B. Autoimmune hemolytic anemia in adults: primary risk factors and diagnostic procedures. Expert Rev Hematol 2020; 13:585-597. [PMID: 32274943 DOI: 10.1080/17474086.2020.1754791] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is due to autoantibodies against erythrocytes that may arise either because of primary tolerance breakage or along with several associated conditions, including genetic predispositions, congenital syndromes, environmental triggers, autoimmune diseases, immunodeficiencies, and neoplasms. AREAS COVERED This review evaluated the risk of AIHA development in associated conditions and summarized disease-intrinsic risk factors for relapse and outcome. Diagnostic procedures were analyzed to properly identify primary and secondary forms. A Medline including clinical trials, meta-analyses, guidelines, consensus, and case reports, published in the last 30 years were performed. EXPERT OPINION The several associated conditions listed above constitute a risk for AIHA development and should be considered since disease course and therapy may be different. Particularly, AIHA developing after transplant or novel checkpoint inhibitors is an emerging complex entity whose proper therapy is still an unmet need. Concerning intrinsic risk factors, the severity of anemia at onset correlated with the recurrence of relapses, refractoriness, and fatal outcome. This finding reflects the presence of several mechanisms involved in AIHA, i.e. highly pathogenic antibodies, complement activation, and failure of marrow compensation. With the advent of novel target therapies (complement and various tyrosine kinase inhibitors), a risk-adapted therapy for AIHA is becoming fundamental.
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Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Juri Giannotta
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
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11
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Cuperfain AB, Coomes EA, Etchells E. A Grave Case of Vomiting. Am J Med 2018; 131:e459-e460. [PMID: 30055120 DOI: 10.1016/j.amjmed.2018.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Ari B Cuperfain
- Department of Medicine, University of Toronto, Ontario, Canada.
| | - Eric A Coomes
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Edward Etchells
- Department of Medicine, University of Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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12
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Gazzana ML, Souza JJ, Okoshi MP, Okoshi K. Prospective Echocardiographic Evaluation of the Right Ventricle and Pulmonary Arterial Pressure in Hyperthyroid Patients. Heart Lung Circ 2018; 28:1190-1196. [PMID: 30262155 DOI: 10.1016/j.hlc.2018.06.1055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/11/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) occurs in 35% to 65% of hyperthyroid patients. Despite this high frequency, only a few authors have examined the effects of hyperthyroidism treatment on PAH and the right ventricle. We evaluated the effects of hyperthyroidism and its reversal on cardiovascular structure and function using Doppler echocardiography. METHODS We prospectively evaluated 32 patients (42.5±11.9years old) with thyrotoxicosis. Exclusion criteria included previous cardiovascular disease. An echocardiogram was performed at the time of hyperthyroidism diagnosis and after normalisation of free thyroxine (T4) levels. Patients were divided into two groups according to the presence or absence of PAH at the diagnosis, or at two moments, before and after T4 normalisation. RESULTS Graves' disease was the most frequent aetiology (75%) of hyperthyroidism. Pulmonary arterial hypertension was observed in 43.8% of patients. Free T4 concentration was higher in PAH than non-PAH patients. Free T4 normalised after 5 (2.0-10.5; median and percentiles) months of treatment. Cardiac chamber sizes and cardiac output were higher in PAH. Right ventricular (RV) systolic function was impaired in PAH. Cardiac output and free T4 (r=0.42; p<0.05) correlated with pulmonary artery systolic pressure (PASP). Cardiac chamber size, cardiac output, left ventricular ejection fraction, and PASP (34.0±8.6 to 21.7±4.5mmHg) reduced after treatment. Right ventricular myocardial performance index and fractional area change improved after T4 normalisation. CONCLUSIONS Pulmonary arterial hypertension is highly prevalent in hyperthyroid patients and is combined with increased cardiac chambers size and cardiac output, and impaired RV function. Cardiovascular changes are reversible after T4 normalisation in patients without cardiovascular disease.
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Affiliation(s)
- M L Gazzana
- Superior School of Health Sciences, Amazonas State University - UEA, Manaus, Amazonas, Brazil
| | - J J Souza
- Medical School, Amazonas Federal University - UFAM, and Medical School, Nilton Lins University - UNL, Manaus, Amazonas, Brazil
| | - M P Okoshi
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - K Okoshi
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil.
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Sarfo-Kantanka O, Sarfo FS, Ansah EO, Kyei I. Graves Disease in Central Ghana: Clinical Characteristics and Associated Factors. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2018; 11:1179551418759076. [PMID: 29593440 PMCID: PMC5865516 DOI: 10.1177/1179551418759076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 01/10/2018] [Indexed: 01/06/2023]
Abstract
Background Graves disease (GD) has increased in prevalence over the past decade in Africa. Despite this, the condition is not well described, especially in sub-Saharan Africa. Objective We have described the clinical characteristics and associated factors of GD in a cohort of patients attending a resource-limited setting tertiary hospital. Methods Patients were examined thoroughly and systematically tested for the degree of clinical and biochemical thyroid status. Thyroid volume, characteristics, and blood flow were assessed at presentation using ultrasonography. Factors associated with an inability to achieve clinical and biochemical thyroid remission were evaluated using multiple logistic regression analysis. Results Overall, 182 patients were studied, 152 (83.5%) were women with a female:male ratio of 5.1:1.0. The mean age at presentation was 39.9 ± 14.7 years with women significantly older than men. Thyroid-associated orbitopathy (TAO) was observed in 56% of the participants and pretibial myxoedema in 6%. About 84% of the participants were hyperthyroid at presentation, 9% were euthyroid, 4% were hypothyroid, and 3% had subclinical hyperthyroidism. Inability to achieve biochemical and clinical remission at 24 months was associated with increased thyroid volume (odds ratio [OR]: 2.35, 95% confidence interval [CI]: 1.85-2.52, P < .001), presence of TAO (OR: 2.15, 95% CI: 2.12-2.33, P < .001), increased FT3/FT4 ratio (OR: 1.33, 95% CI: 1.24-2.56, P = .004), and missed clinic appointment (OR: 5.2, 95% CI: 4.55-7.89, P < .001). Conclusions Graves disease among Ghanaians is associated with significant signs at presentation. Inability to achieve remission within the first 24 months is associated with increased thyroid volume, TAO, an increased FT3/FT4 ratio, as well as missed clinic appointment.
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Affiliation(s)
| | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Ishmael Kyei
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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14
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Garla VV, Abdul Salim S, Yanes-Cardozo LL. Pancytopenia: a rare complication of Graves' disease. BMJ Case Rep 2018. [PMID: 29525760 DOI: 10.1136/bcr-2017-223887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
A 27-year-old male patient who presented to the emergency room with complaints of sweating, palpitations, heat intolerance, insomnia and weight loss for the last 3 months. His medical history was significant for hypertension. On examination, he was tachycardic, hypertensive, had tremors of the upper extremities and a smooth goitre with a thyroid bruit. Laboratory assessment revealed a suppressed thyroid-stimulating hormone, high free thyroxine and positive thyroid receptor antibodies. Complete blood count showed pancytopenia. As part of the work-up for pancytopenia, haptoglobin, ferritin, Coombs test, reticulocyte count hepatitis B and C antibodies were done, all of which were normal. Patient was started on methimazole, propranolol and hydrocortisone. His symptoms improved through the hospital course and he was subsequently discharged. Thyroidectomy was done once the patient's hyperthyroidism was controlled. Levothyroxine was started for the control of postsurgical hypothyroidism. Six months after thyroidectomy, the patient was euthyroid and the pancytopenia resolved.
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Affiliation(s)
- Vishnu Vardhan Garla
- Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Sohail Abdul Salim
- Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Licy L Yanes-Cardozo
- Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
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15
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Moore JA, Gliga L, Nagalla S. Thyroid storm and warm autoimmune hemolytic anemia. Transfus Apher Sci 2017; 56:606-608. [PMID: 28870408 DOI: 10.1016/j.transci.2017.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 12/31/2022]
Abstract
Graves' disease is often associated with other autoimmune disorders, including rare associations with autoimmune hemolytic anemia (AIHA). We describe a unique presentation of thyroid storm and warm AIHA diagnosed concurrently in a young female with hyperthyroidism. The patient presented with nausea, vomiting, diarrhea and altered mental status. Laboratory studies revealed hemoglobin 3.9g/dL, platelets 171×109L-1, haptoglobin <5mg/dL, reticulocytosis, and positive direct antiglobulin test (IgG, C3d, warm). Additional workup revealed serum thyroid stimulating hormone (TSH) <0.01μIU/mL and serum free-T4 (FT4) level 7.8ng/dL. Our patient was diagnosed with concurrent thyroid storm and warm AIHA. She was started on glucocorticoids to treat both warm AIHA and thyroid storm, as well as antithyroid medications, propranolol and folic acid. Due to profound anemia and hemodynamic instability, the patient was transfused two units of uncrossmatched packed red blood cells slowly and tolerated this well. She was discharged on methimazole as well as a prolonged prednisone taper, and achieved complete resolution of the thyrotoxicosis and anemia at one month. Hyperthyroidism can affect all three blood cell lineages of the hematopoietic system. Anemia can be seen in 10-20% of patients with thyrotoxicosis. Several autoimmune processes can lead to anemia in Graves' disease, including pernicious anemia, celiac disease, and warm AIHA. This case illustrates a rarely described presentation of a patient with Graves' disease presenting with concurrent thyroid storm and warm AIHA.
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Affiliation(s)
- Joseph A Moore
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Louise Gliga
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Srikanth Nagalla
- Division of Hematology Oncology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
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16
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Atypical Complications of Graves' Disease: A Case Report and Literature Review. Case Rep Endocrinol 2017; 2017:6087135. [PMID: 28348902 PMCID: PMC5350306 DOI: 10.1155/2017/6087135] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/13/2017] [Indexed: 12/04/2022] Open
Abstract
Graves' disease (GD) may display uncommon manifestations. We report a patient with rare complications of GD and present a comprehensive literature review. A 35-year-old woman presented with a two-week history of dyspnea, palpitations, and edema. She had a raised jugular venous pressure, goiter, and exophthalmos. Laboratory tests showed pancytopenia, a raised alkaline phosphatase level, hyperbilirubinemia (mainly direct bilirubin), and hyperthyroidism [TSH: <0.01 mIU/L (reference values: 0.45–4.5), fT4: 54.69 pmol/L (reference values: 9.0–20.0), and fT3: >46.08 pmol/L (reference values: 2.6–5.7)]. Her thyroid uptake scan indicated GD. Echocardiography showed a high right ventricular systolic pressure: 60.16 mmHg. Lugol's iodine, propranolol, cholestyramine, and dexamethasone were initiated. Hematologic investigations uncovered no reason for the pancytopenia; therefore, carbimazole was started. Workup for hepatic impairment and pulmonary hypertension (PH) was negative. The patient became euthyroid after 3 months. Leukocyte and platelet counts and bilirubin levels normalized, and her hemoglobin and alkaline phosphatase levels and right ventricular systolic pressure (52.64 mmHg) improved. This is the first reported single case of GD with the following three rare manifestations: pancytopenia, cholestatic liver injury, and PH with right-sided heart failure. With antithyroid drugs treatment, pancytopenia should resolve with euthyroidism, but PH and liver injury may take several months to resolve.
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17
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Scicchitano P, Dentamaro I, Tunzi F, Ricci G, Carbonara S, Devito F, Zito A, Ciampolillo A, Ciccone MM. Pulmonary hypertension in thyroid diseases. Endocrine 2016; 54:578-587. [PMID: 26994930 DOI: 10.1007/s12020-016-0923-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/10/2016] [Indexed: 12/15/2022]
Abstract
The influence of thyroid hormones on cardiovascular system is well established. Thyroid diseases can effectively enhance the alteration on cardiovascular system by influencing chronotropic and inotropic actions of the heart; altering the strength and the speed of contraction, the speed of relaxation, the duration of the potential of action, and the duration of the refractory period and atrio-ventricular conduction time; modulating circulation and peripheral vascular beds. One of the more intriguing insights in the connection between thyroid diseases and cardiovascular alterations is related to the evaluation of the influence of thyroid hormones on pulmonary vascular beds. Literature reported several studies regarding the association between both hypothyroidism and hyperthyroidism and the occurrence of increased vascular pulmonary arterial pressure. Nevertheless, the pathogenetic mechanisms able to explain such relationship are not fully understood. Many doubts still persist in the comprehension of the mechanisms of pulmonary hypertension in thyroid diseases. The aim of this review was to provide possible explanation about the possible interaction between pulmonary vascular beds and thyroid function in order to evaluate the possibility of novel perspectives in the general management of patients suffering from thyroid and cardiovascular diseases.
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Affiliation(s)
| | - Ilaria Dentamaro
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Tunzi
- Cardiology Section, Hospital of Gallipoli, ASL LE, Gallipoli, Lecce, Italy
| | - Gabriella Ricci
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Santa Carbonara
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Fiorella Devito
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Annapaola Zito
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Anna Ciampolillo
- Section of Endocrinology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare 11, 70124, Bari, Italy.
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18
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Fouad YM, Yehia R. Hepato-cardiac disorders. World J Hepatol 2014; 6:41-54. [PMID: 24653793 PMCID: PMC3953805 DOI: 10.4254/wjh.v6.i1.41] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 11/19/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Understanding the mutual relationship between the liver and the heart is important for both hepatologists and cardiologists. Hepato-cardiac diseases can be classified into heart diseases affecting the liver, liver diseases affecting the heart, and conditions affecting the heart and the liver at the same time. Differential diagnoses of liver injury are extremely important in a cardiologist's clinical practice calling for collaboration between cardiologists and hepatologists due to the many other diseases that can affect the liver and mimic haemodynamic injury. Acute and chronic heart failure may lead to acute ischemic hepatitis or chronic congestive hepatopathy. Treatment in these cases should be directed to the primary heart disease. In patients with advanced liver disease, cirrhotic cardiomyopathy may develop including hemodynamic changes, diastolic and systolic dysfunctions, reduced cardiac performance and electrophysiological abnormalities. Cardiac evaluation is important for patients with liver diseases especially before and after liver transplantation. Liver transplantation may lead to the improvement of all cardiac changes and the reversal of cirrhotic cardiomyopathy. There are systemic diseases that may affect both the liver and the heart concomitantly including congenital, metabolic and inflammatory diseases as well as alcoholism. This review highlights these hepatocardiac diseases.
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Affiliation(s)
- Yasser Mahrous Fouad
- Yasser Mahrous Fouad, Reem Yehia, Gastroenterology and Hepatology Unit, Endemic Medicine Department, Minia University, Minia 19111, Egypt
| | - Reem Yehia
- Yasser Mahrous Fouad, Reem Yehia, Gastroenterology and Hepatology Unit, Endemic Medicine Department, Minia University, Minia 19111, Egypt
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19
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Graves' disease causing pancytopenia and autoimmune hemolytic anemia at different time intervals: a case report and a review of the literature. Case Rep Med 2013; 2013:194542. [PMID: 24319463 PMCID: PMC3844236 DOI: 10.1155/2013/194542] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/24/2013] [Indexed: 12/13/2022] Open
Abstract
Graves' disease (GD) is associated with various hematologic abnormalities but pancytopenia and autoimmune hemolytic anemia (AIHA) are reported very rarely. Herein, we report a patient with GD who had both of these rare complications at different time intervals, along with a review of the related literature. The patient was a 70-year-old man who, during a hospitalization, was also noted to have pancytopenia and elevated thyroid hormone levels. Complete hematologic workup was unremarkable and his pancytopenia was attributed to hyperthyroidism. He was started on methimazole but unfortunately did not return for followup and stopped methimazole after a few weeks. A year later, he presented with fatigue and weight loss. Labs showed hyperthyroidism and isolated anemia (hemoglobin 7 g/dL). He had positive direct Coombs test and elevated reticulocyte index. He was diagnosed with AIHA and started on glucocorticoids. GD was confirmed with elevated levels of thyroid stimulating immunoglobulins and thyroid uptake and scan. He was treated with methimazole and radioactive iodine ablation. His hemoglobin improved to 10.7 g/dL at discharge without blood transfusion. Graves' disease should be considered in the differential diagnosis of hematologic abnormalities. These abnormalities in the setting of GD generally respond well to antithyroid treatment.
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Kim TH, Yoon JS, Park BS, Lee DW, Cho JH, Moon JS, Kim EH, Won KC, Lee HW. A Case of Pancytopenia with Hyperthyroidism. Yeungnam Univ J Med 2013. [DOI: 10.12701/yujm.2013.30.1.47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tae Hoon Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Ji Sung Yoon
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Byung Sam Park
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Dong Won Lee
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jae Ho Cho
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jun Sung Moon
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Eui Hyun Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Kyu Chang Won
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Hyoung Woo Lee
- Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, Korea
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