AN EXUDATIVE PLEURAL EFFUSION ASSOCIATED WITH GRAVES DISEASE

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Graves’ disease is an autoimmune disease associated with hyperthyroidism and antithyroid autoantibodies. Ocular and dermatologic findings are well described extrathyroid manifestations of Graves’ disease. Here we present a case of pleural effusion as an extrathyroid manifestation of Graves’ disease. CASE PRESENTATION: A 42-year-old African American male with a history of traumatic pneumothorax presented with five days of dyspnea and cough with scant hemoptysis. He reported associated subjective fever, chills, left sided pleuritic chest pain, recent sick contacts and a twenty pound weight loss over the last year. Tachycardia and tachypnea as well as decreased breath sounds over right lower lung fields and rhonchi over left lower lung fields were present on exam. Computed tomography angiography was performed in the emergency department and revealed patchy left sided infiltrates, marked thyromegaly, cardiomegaly and a moderate right sided effusion. He received ceftriaxone and azithromycin as treatment for community acquired pneumonia. Laboratory evaluation was notable for TSH 0.01 mcIU/mL and Free T4 >7.7 ng/dL consistent with hyperthyroidism. Thyrotropin receptor antibody was also significantly elevated raising concern for Graves’ disease. Transthoracic echocardiogram revealed dilated cardiomyopathy with moderately reduced ejection fraction (35%). Thoracentesis of right pleural effusion was performed on hospital day two and returned 1200cc amber colored fluid. Fluid studies were consistent with an exudative effusion (pleural/serum protein ratio 0.58) and cell count was lymphocyte predominant (77%). Gram stain and fluid cultures revealed no growth. Adenosine deaminase was not elevated, and cytology was unremarkable. Prior to discharge, the patient was started on methimazole as management of his Graves’ disease. Repeat chest x-ray three months later revealed persistent resolution of the pleural effusion. DISCUSSION: Pleural effusion is a rare but reported manifestation of Graves’ disease. Effusions are exudative and thus other common causes of exudates should also be ruled out. The pathophysiology is thought to be an autoimmune mediated epiphenomenon similar to pretibial myxedema and ophthalmopathy associated with Graves’ disease. CONCLUSIONS: In patients with uncontrolled hyperthyroidism and an exudative pleural effusion, Graves’ disease should be considered as a potential etiology. Reference #1: Fatourechi, V. (2015). Thyroid dermopathy and acropachy. In Graves' Disease (pp. 195-212). Springer, New York, NY. Reference #2: Kapur, S., & Olarewaju, A. (2014). Pleural Effusion in the Setting of Graves’ Disease and Congestive Heart Failure: A Case Report. Chest, 145(3), 257A. Reference #3: Khalid, Y., Sulaiman, R., Zahir, R., Baskar, V., & Buch, H. N. (2011). An unusual complication in a patient with Graves’ disease. Clinical Correspondence. DISCLOSURES: No relevant relationships by William Denney, source=Web Response no disclosure on file for Jessie Harvey