Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II |

Pulmonary Hypertension in Hyperthyroidism: A Reversible Cause FREE TO VIEW

Sagar Patel, MD; Nikul Patel, DO
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Albert Einstein Medical Center, Philadelphia, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1100A. doi:10.1016/j.chest.2016.08.1207
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Thyroid gland dysfunction greatly alters the hemodynamics of the body resulting in major changes in cardiac output, blood pressure and pulmonary vascular resistance amongst others. Hyperthyroidism is a reversible cause of pulmonary hypertension. When the underlying hormonal imbalance is corrected, the result is improved cardiovascular outcomes and symptoms. Usually, the etiology in these cases is toxic multi-nodular goiter but can also occur with other causes of hyperthyroidism.

CASE PRESENTATION: We present a 42 year old female with Graves’ disease with a history of thyroid storm, schizophrenia and non-compliance with medications who was brought to the ED to obtain medical clearance for psychiatric treatment. She was exhibiting hostile, bizarre and paranoid behavior. She refused all medical care and was involuntarily committed for mental and physical care. Upon arrival, her BP was 161/96, HR 156, RR 22, Temp 37.4oC, Sat 98% on RA. A large goiter was visible. She endorsed symptoms of cough and shortness of breath but denied fever, chills, chest pain or hemoptysis. Blood work showed a TSH <0.01, T4 free 3.98, and T3 total 800.64. Impending thyroid storm was diagnosed and treatment was initiated with propylthiouracil, propranolol and hydrocortisone. Her mood improved, she was less hostile, and more cooperative with medical treatments; however, her dyspnea remained unchanged. Diagnostic workup included a normal CXR, thyroid US showing heterogeneous enlargement, and a V/Q scan resulting in low probability for PE. Echocardiogram showed a hyper dynamic LV, mildly dilated RV with PASP >70mmHg. She was deemed a poor candidate for long term medical therapy and a decision was made for total thyroidectomy during this admission once the patient achieved a euthyroid state. Her symptoms remained stable and surgery was performed 2 weeks after admission. Her dyspnea quickly improved and repeat measurements showed an improved PASP of 50mmHg.

DISCUSSION: Vast majority of patients with hyperthyroidism who develop pulmonary hypertension will have moderate pulmonary hypertension (41-55mmHg). Our patient exhibited severe PAH (>70mmHg) which is unusual. The rapid decrease in her pulmonary hypertension highlighted the need for aggressive early management including surgery, which may prevent the debilitating effects of cardiovascular decline in the future.

CONCLUSIONS: With recent studies showing the prevalence of PAH in hyperthyroidism to be as high as 40%, this entity requires more investigation to establish guidelines for early aggressive management and time interval for follow up.

Reference #1: Recenti Prog Med. 2004 Sep;95(9):443-6. Thyroid dysfunction and pulmonary hypertension. Marvisi M, Ajolfi C, Civardi G, Delsignore R

Reference #2: Am J Med Sci. 2011 Dec: Hyperthyroidism and pulmonary hypertension: an important association

Reference #3: Panminerva Med 2013 Mar;55(1):93-7. Thyroid gland and pulmonary hypertension. What's the link?

DISCLOSURE: The following authors have nothing to disclose: Sagar Patel, Nikul Patel

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