9371 Insult To Injury: A Rare Presentation Of Graves’ Disease With Acute Pericarditis
Authors: Shaik Kamal , Nayeem Atika , Kartoumah Anas , Alsheikh Jad , Horani Mohamad Hosam 
Published: October 2024

Abstract
Disclosure: K. Shaik: None. A. Nayeem: None. A. Kartoumah: None. J. Alsheikh: None. M.H. Horani: None.
Introduction: Graves' disease is an autoimmune condition that primarily causes hyperthyroidism. Its impact often extends to the cardiovascular system, causing complications such as atrial fibrillation and tachycardia. However, the co-occurrence of acute pericarditis is unusually rare and underreported. This case report explores this uncommon presentation, aiming to enhance current treatment procedures of this rare co-occurrence. Case Presentation: A 57-year-old female with a past medical history of chronic back pain, prediabetes, and peptic ulcer disease presented to the ED with a two-day history of chest pressure and shortness of breath, with associated diaphoresis. The patient was referred to the ED after an EKG performed in Urgent Care revealed tachycardia at 126 bpm. The patient recalled a similar episode a few months ago that lasted three days and resolved spontaneously.On examination in the ED, she was tachycardic (109 bpm) and had elevated T3 (3.97) and T4 (1.66). She was subsequently admitted for suspected thyroid storm and administered 15 mg Toradol, 0.5 mg Ativan, 5 mg methimazole every 8 hours, 20 mg propranolol every 8 hours, and 1L LR bolus. While in the hospital, a repeat EKG showed some ST elevations, but subsequent cardiac catheterization was negative for any vessel disease or occlusion. A repeat echocardiogram showed a preserved ejection fraction of 50 to 55%, with moderate pericardial effusion. The patient underwent a pericardiocentesis, draining approximately 300 cc of fluid. Further testing revealed she was positive for thyroglobulin receptor antibody (TRAb), confirming Graves' disease. However, a thyroid ultrasound and CT abdomen were negative for any abnormal masses that could have been alternative sources of elevated T3 and T4. Ultimately, the patient remained medically stable for discharge home with methimazole 5 mg every 8 hours, colchicine 0.6 mg twice daily, ibuprofen 600 mg 3 times daily, as well as Protonix 40 mg p.o. daily for prophylaxis. Discussion: Graves’ disease, usually characterized by autoimmune hyperthyroidism, often also manifests with cardiovascular complications. However, the co-occurrence of acute pericarditis with Graves’ disease is rare and not commonly reported. Some speculate direct autoimmune involvement, while others suggest a metabolic impact from acute thyrotoxicosis. Nonetheless, prompt treatment is necessary, and first-line treatment for thyroid pericarditis usually involves the usage of NSAIDS, colchicine, and beta-blockers. Recurrent pericarditis may necessitate long-term management with corticosteroids or other immunomodulatory therapies. Conclusion: Graves’ disease presenting as pericarditis is not commonly observed. While an exact pathophysiological mechanism does not exist that can explain this association, medical professionals should remain vigilant against this co-occurrence.
Presentation: 6/1/2024