Diagnosis and Treatment > Medication
Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Heath Park, Cardiff, UK
Search for other papers by J K Witczak in
Google Scholar
PubMed
Search for other papers by N Ubaysekara in
Google Scholar
PubMed
Search for other papers by R Ravindran in
Google Scholar
PubMed
Search for other papers by S Rice in
Google Scholar
PubMed
Search for other papers by Z Yousef in
Google Scholar
PubMed
Search for other papers by L D Premawardhana in
Google Scholar
PubMed
Summary
Graves’ disease is associated with tachydysrythmia, cardiac ischaemia and cardiomyopathy – all uncommon in young adults without previous cardiac disease. We present three young individuals who developed cardiac complications after periods of uncontrolled Graves’ disease. Subject 1: A 34-year-old female had severe thyrotoxic symptoms for weeks. Investigations showed fT4: 98.4 (11–25 pmol/L), fT3: 46.9 (3.1–6.8 pmol/L), TSH <0.01 (0.27–4.2 mU/L) and thyrotrophin receptor antibody (TRAb): 34.8 (<0.9 U//l). She had appropriate treatment but several weeks later she became breathless despite improving thyroid function. Echocardiography showed a pericardial effusion of 2.9 cm. She responded well to steroids and NSAIDs but developed active severe Graves’ orbitopathy after early total thyroidectomy. Subject 2: A 28-year-old male developed thyrotoxic symptoms (fT4: 38 pmol/L, fT3: 13.9 pmol/L, TSH <0.01 (for over 6 months) and TRAb: 9.3 U/L). One month after starting carbimazole, he developed acute heart failure (HF) due to severe dilated cardiomyopathy – EF 10–15%. He partially recovered after treatment – EF 28% and had early radioiodine treatment. Subject 3: A 42-year-old woman who had been thyrotoxic for several months (fT4: 54.3; fT3 >46.1; TSH <0.01; TRAb: 4.5) developed atrial fibrillation (AF) and heart failure. Echocardiography showed cardiomegaly – EF 29%. She maintains sinus rhythm following early total thyroidectomy (EF 50%). Significant cardiac complications may occur in previously fit young adults, who have had uncontrolled Graves’ disease for weeks to months. Cardiac function recovers in the majority, but early definitive treatment should be discussed to avoid Graves’ disease relapse and further cardiac decompensation.
Learning points:
-
Cardiac complications of Graves’ disease are uncommon in young adults without previous cardiac disease.
-
These complications may however occur if Graves’ disease had been poorly controlled for several weeks or months prior to presentation.
-
Persistent symptoms after adequate control should alert clinicians to the possibility of cardiac disease.
-
Specific treatment of Graves’ disease and appropriate cardiac intervention results in complete recovery in the majority and carries a good prognosis.
-
Early definitive treatment should be offered to them to prevent cardiac decompensation at times of further relapse.
Search for other papers by Omayma Elshafie in
Google Scholar
PubMed
Search for other papers by Yahya Al Badaai in
Google Scholar
PubMed
Search for other papers by Khalifa Alwahaibi in
Google Scholar
PubMed
Search for other papers by Asim Qureshi in
Google Scholar
PubMed
Search for other papers by Samir Hussein in
Google Scholar
PubMed
Search for other papers by Faisal Al Azzri in
Google Scholar
PubMed
Search for other papers by Ali Almamari in
Google Scholar
PubMed
Search for other papers by Nicholas Woodhouse in
Google Scholar
PubMed
Summary
A 48-year-old hypertensive and diabetic patient presented with a 10-year history of progressive right facial pain, tinnitus, hearing loss, sweating, and palpitations. Investigations revealed a 5.6 cm vascular tumor at the carotid bifurcation. Her blood pressure (BP) was 170/110, on lisinopril 20 mg od and amlodipine 10 mg od and 100 U of insulin daily. A catecholamine-secreting carotid body paraganglioma (CSCBP) was suspected; the diagnosis was confirmed biochemically by determining plasma norepinephrine (NE) level, 89 000 pmol/l, and chromogranin A (CgA) level, 279 μg/l. Meta-iodobenzylguanidine and octreotide scanning confirmed a single tumor in the neck. A week after giving the patient a trial of octreotide 100 μg 8 h, the NE level dropped progressively from 50 000 to 25 000 pmol/l and CgA from 279 to 25 μg/l. Treatment was therefore continued with labetalol 200 mg twice daily (bid) and long-acting octreotide-LA initially using 40 mg/month and later increasing to 80 mg/month. On this dose and with a reduced labetalol intake of 100 mg bid, BP was maintained at 130/70 and her symptoms resolved completely. CgA levels returned to normal in the first week and these were maintained throughout the 3 month treatment period. During tumor resection, there were minimal BP fluctuations during the 10 h procedure. We conclude that short-term high-dose octreotide-LA might prove valuable in the preoperative management of catecholamine-secreting tumors. To the best of our knowledge, this is the first report on the successful use of octreotide in a CSCBP.
Learning points
-
The value of octreotide scanning in the localization of extra-adrenal pheochromocytoma.
-
Control of catecholamine secretion using high-dose octreotide.
-
This is a report of a rare cause of secondary diabetes and hypertension.
