Endocrine Abstracts

Introduction: Grave’s disease is common, with estimated prevalence between 0.2% and 2%. Sympathetic overdrive secondary to Grave’s disease can complicate compliance issues. We present a complex case of severe mitral regurgitation secondary to poorly controlled Grave’s disease for 11 years, and the subsequent need for urgent definitive inpatient treatment.

Case Presentation: 30-year-old female attended the Emergency Department with palpitations, agitation, headache and abdominal pain. Past medical history includes Grave’s disease, Generalized anxiety & depression. Since diagnosis in 2014, she had recurrent missed appointments with Endocrinology and surgical teams for review of pharmacological and non-pharmacological management. Biochemical investigations confirmed thyrotoxicosis (TSH <0.05 mIU/l, free T3 >30.72 pmol/l and free T4 34.7 pmol/l). She admitted long-standing non-compliance to medication and prior allergic reaction to Propylthiouracil. Carbimazole 40 mg once-daily and Propranolol 40 mg three-times-daily were restarted. During admission, she developed worsening dyspnoea and non-productive cough. Investigations confirmed concerns of heart failure with elevated BNP (5357 ng/l) and chest X-ray revealed pulmonary congestion. Echo showed severe mitral regurgitation secondary to anterior mitral valve leaflet prolapse; most likely secondary to poorly controlled thyrotoxicosis. After multidisciplinary discussion involving the patient and her family, it was agreed to proceed with inpatient thyroidectomy. Lugol’s iodine 5 drops three-times-daily was commenced, and thyroidectomy (uncomplicated) was conducted four days later, after stabilization of thyroid function tests. She recovered well post-operatively and will have close outpatient follow-up with Endocrinology, Surgical and Cardiology teams.

Discussion: Mitral valve regurgitation is common secondary to Grave’s disease, occurring in up to 13% of patients. With aggressive treatment of thyrotoxicosis, it has potential reversibility. Our case highlights a complex situation of non-compliance to medication for eleven years and subsequent severe cardiovascular impairment. We emphasise the need for urgent action and support in these vulnerable patients, to prevent end-stage complications of this significant disease.