A Series of Unfortunate Events

Dilated Thyrotoxic Cardiomyopathy Resulting in Cardioembolic

Stroke in a Young Man with Unrecognized Graves Disease
Soamsiri Niwattisaiwong MD1, Mana Dissadee MD2, Toyiba Syed MD1, Jennifer Bernard MD1
1Advocate Illinois Masonic Medical Center, 2Rosalind Franklin University of Medicine and Science

INTRODUCTION

CASE PRESENTATION

CASE PRESENTATION

Hyperdynamic circulatory state is the most

profound and characteristic feature of
thyrotoxicosis.

The diagnosis of DTC was made. The patient

was immediately intubated due to respiratory
distress.

Despite increased cardiac performance, 6% of

thyrotoxic patients develop high-output
congestive heart failure.

Treatment with propranolol, high dose PTU,

hydrocortisone, potassium iodide, diuretics,
angiotensin-converting enzyme inhibitor, and
inotropes was initiated.

Paradoxically, less than 1% of patients develop

thyrotoxic dilated cardiomyopathy (DTC) with
impaired left ventricular (LV) systolic function.

We describe a rare case of DTC secondary to

Graves disease, whose clinical course was
complicated with a cardioembolic stroke.

CASE PRESENTATION

History

18-year-old previously healthy man

with 10-day history of increasing
shortness of breath, fatigue, and
palpitations
20-lb weight loss in 2 months
Heat intolerance
Generalized weakness

Physical
exam

Blood pressure 114/70 mmHg

Regular pulse 140/min
Respiratory rate 38/min
Temperature 97.6 F
Lethargic, warm & moist skin
No proptosis, lid lag or lid retraction
Diffuse thyroid enlargement
with bruit
Jugular venous distension
Tachycardia with S3 gallop, no
murmur
Rales in both lung bases

Fig. 1: Chest X-ray showed cardiomegaly and pulmonary edema

Fig. 2: Initial
EKG
showed
sinus
tachycardia,
left
ventricular
hypertrophy,
and nonspecific STT wave
change.

Test
TSH
Free T4
Total T3
Thyroid peroxidase
antibody
Thyroglobulin
antibody
Thyroid stimulating
antibody

Repeated echocardiogram with bubble study

was negative for intracardiac shunting. LVEF
was 30%, improved as compared to previous
echo. Retrospective review of telemetry strip
showed persistent sinus tachycardia without
atrial fibrillation (AF).
Decompressive craniectomy was performed.
The patient became ventilator-dependent and
was discharged with permanent neurodeficit.

Patient
< 0.03 mIU/L
3.18 ng/dL
2.13 ng/dL

Reference range
0.34-5.60 mIU/L
0.58-1.64 ng/dL
0.87-1.78 ng/dL

586 IU/mL

<9.0 IU/mL

DTC is a rare complication of hyperthyroidism.

75 IU/mL

<116 IU/mL

389 %

<130%

Thyroid hormone (TH) may alter the expression

of cardiac proteins, leading to contractile
dysfunction and DTC.

Table 1: Thyroid function tests and antibodies

Normal complete blood count,

electrolytes, renal function, and
Laboratory
cardiac enzymes
tests
Thyroid function test and
antibodies compatible with
Graves disease (Table 1)

Fig. 3: CT brain revealed a large

acute infarction in the left
frontoparietal region

A week later, he
became less
responsive with
fixed dilated
pupils and
absent gag
reflex. CT brain
was immediately
ordered (Fig. 3).

Echocardiography demonstrated severe LV

systolic dysfunction with ejection fraction (EF)
15%. There was no intracardiac thrombi or
valvular abnormalities visualized.

DISCUSSION

Chronic tachycardia also plays a role in DTC

development by increasing the level of cytosolic
calcium during diastole, resulting in reduced
ventricular contractility and diastolic dysfunction.
Treatment of hyperthyroidism usually results in
rapid resolution of DTC.

DISCUSSION
Fig. 4: LV
performance
assessed by the
LVEF (%) before
and after 6-12
months of
hyperthyroid
treatment in 7
patients with DTC.
Adapted from Congestive
Heart Failure Due to
Reversible Cardiomyopathy in
Patients with Hyperthyroidism
by Guillermo et al.

Hyperthyroidism is hypothesized to increase the

risk of thrombosis.
The mechanism of TH-induced hypercoagulable
state is not well established, but possibly by
modifying the coagulation-fibrinolytic balance.
Cardioembolic stroke is a serious complication
of thyrotoxic AF and DTC. Our patient likely
developed LV thrombus in the setting of DTC.
The hypercoagulable state in hyperthyroidism
possibly made him prone to thrombus
formation.

CONCLUSION
DTC is a rare presentation of hyperthyroidism
and is associated with increased cardiovascular
morbidity and mortality, mainly due to heart
failure and cardioembolism.
Awareness of this uncommon presentation of
hyperthyroidism is essential to identify patients
with potentially reversible dilated
cardiomyopathy.

REFERENCE
Guillermo et al. Congestive Heart Failure Due to Reversible
Cardiomyopathy. Am J Med Sci 1995; 310(3):99-101.
Squizzato et al. Clinical Review: Thyroid Dysfunction and Effects
on Coagulation and Fibrinolysis: A Systematic Review. JCEM
2007; 92(7):2415-2420.
Klein et al. Thyroid Hormone and the Cardiovascular System.
NEJM 2001; 344(7):501-509.