Introduction: Hyperthyroidism secondary to Graves disease is well-recognised to be associated with non-thyroidal immunological manifestations like ophthalmopathy and pretibial myxoedema. We report a patient with Graves disease who presented with an unusual complication.
Case: A 68 year old Caucasian lady presented with typical features of hyperthyroidism which was confirmed by free T4 72.0 pmol/l (12.022.0 pmol/l) and TSH <0.01 mU/l (0.274.20 mU/l). Graves disease was confirmed by diffusely increased uptake on radio-nuclide scan and TSH receptor antibodies level of 13 U/l (normal <1.0 U/l). She was commenced on carbimazole and beta-blockers. Shortly thereafter she was admitted to hospital with shortness of breath and atrial fibrillation with a fast ventricular rate. She had a loud pericardial rub and raised jugular venous pressure. Chest X-ray showed cardiomegaly and mild pleural effusion. An urgent echocardiogram confirmed moderately large global pericardial effusion but there were no features of cardiac tamponade. WCC 20.5, CRP 187, ESR 75, autoantibodies were negative and complement levels were normal. Pleural biopsy showed benign inflammatory changes. Stable euthyroidism was maintained with block and replacement therapy and 6 weeks after commencement of anti-thyroid therapy a repeat echocardiogram confirmed resolution of pericardial effusion and inflammatory markers normalised. Unfortunately pleural effusion was complicated by secondary infection leading to empyema requiring intercostal drainage and antibiotic therapy. Six months later, she remains euthyroid with no serous membrane involvement.
Discussion: We believe that pericardial and pleural effusions were related to Graves disease with which they had a strong temporal relationship. Other causes for serous membrane involvement were excluded. Although this is uncommon it has been previously described and inflammatory changes related to an autoimmune process are considered to be involved.
Conclusion: Pleural and pericardial effusions are rare but recognised and serious complications of Graves disease and should be considered in patients who present with dyspnoea or chest pain.