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Disorders of the Pleura |

Pleural Effusion in the Setting of Graves' Disease and Congestive Heart Failure: A Case Report

Sakshi Kapur, MD; Ayodeji Olarewaju, MBChB
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Overlook Medical Center, Summit, NJ


Chest. 2014;145(3_MeetingAbstracts):257A. doi:10.1378/chest.1771261
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Abstract

SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Hyperthyroidism is a rare cause of pleural effusion. We report a case of pleural effusion associated with Grave’s disease in a patient with congestive heart failure.

CASE PRESENTATION: A 42 year old male presented with six months of diarrhea, two months of bilateral leg swelling and ten days of shortness of breath, palpitations and productive cough. He had tachypnea, tachycardia and a normal blood pressure with bilateral exophthalmos and signs of congestive heart failure. His thyroid gland was diffusely enlarged but non-tender. Breath sounds were absent in his right hemithorax. Workup revealed elevated BNP, fT4 and fT3 with low TSH. EKG showed atrial fibrillation with a ventricular rate of 150 beats/min. CT scan showed large right and moderate left pleural effusion. Thoracentesis yielded two liters of “tea” colored fluid with chemical analysis suggestive of an exudate. Echocardiogram revealed an ejection fraction of 30%. Initial clinical impression was Grave’s disease complicated by atrial fibrillation and CHF with bilateral pleural effusion. He received propylthiouracil, intravenous furosemide, diltiazem and heparin. Twenty days later, he presented with recurrent right sided pleural effusion requiring a repeat thoracentesis. He had been non-compliant with his propylthiouracil. Six months later, his hyperthyroidism was controlled and he had no recurrence of his pleural effusion.

DISCUSSION: Effusions (pleural and pericardial) are rare in hyperthyroidism and predominantly reported in patients with Grave’s disease1, 2. A similar immunological mechanism to pretibial myxedema and ophthalmopathy has been proposed for these effusions1. Our patient was initially thought to have pleural effusion secondary to CHF. Pleural fluid analysis showed an exudate which is compatible with the use of diuretics. His pleural - serum albumin gradient was however less than 1.2 g/dl, suggesting that the fluid was truly an exudate. Other potential causes of exudative pleural effusion were ruled out and there was a resolution of his pleural effusion with adequate control of his hyperthyroidism. This strongly indicates that his pleural effusion was caused by Grave’s disease. Anti-thyroid medications and thoracentesis are adequate treatment modalities in most cases. Methimazole is associated with ANCA positive vasculitis and lupus-like syndrome which can also cause pleural effusion. We suggest that methimazole should be avoided in patients with pleural effusions associated with (Grave’s) hyperthyroidism.

CONCLUSIONS: Grave’s hyperthyroidism should be considered in the differential diagnosis of pleural effusion in patients with thyrotoxicosis and CHF.

Reference #1: NZMJ 26 August 2011, Vol 124 No 1341; ISSN 1175 8716

Reference #2: Tex Heart Inst J. 2007; 34(1): 88-90.

DISCLOSURE: The following authors have nothing to disclose: Sakshi Kapur, Ayodeji Olarewaju

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