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Acute pericarditis, Graves’ disease, and thymic hyperplasia: a case report

ABSTRACT: Abstract

Background

Acute pericarditis as a sign of mediastinal mass is rare and aetiological diagnosis can be challenging without adequate imaging.

Case summary

An 18-year-old woman came to our attention describing acute sharp chest pain radiated to the left arm, exacerbated with supine positioning and attenuated while sitting or leaning forward. The electrocardiogram showed diffuse ST elevation and PR depression, with sinus tachycardia. Cardiac biomarkers and D-dimer were negative; echocardiography showed no abnormalities and the absence of pericardial effusion. Her blood work revealed no sign of inflammation or bacterial infection (PCR and procalcitonin were normal); thyroid-stimulating hormone plasma levels were suppressed, showing decompensated thyrotoxicosis. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Epstein–Barr virus, human immunodeficiency virus, hepatitis C virus, Enterovirus, Parvovirus B19, and Adenovirus tests were normal. Her past medical history was silent, apart from Grave’s disease on treatment with methimazole. Chest computed tomography (CT) was performed and showed the presence of slightly increased density pericardial effusion, with a maximum thickness of 15 mm in the upper mediastinum. Finally, cardiac magnetic resonance (MR) identified a mass of 73 × 51 mm located in the upper mediastinum. The mass was subsequently biopsed with video-assisted thoracoscopic surgery and the histological analysis showed thymic hyperplasia.

Discussion

This case shows the importance of an adequate clinical suspicion of thymic hyperplasia in the context of acute pericarditis symptoms and known Graves’ disease. In this case, a negative chest CT finding may not be sufficient to rule out the diagnosis and cardiac MR imaging is necessary.

SUBMITTER: Acquaro M

PROVIDER: S-EPMC8526917 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundAcute pericarditis is frequently encountered in clinical practice; however, pericarditis as the first presentation of Graves' disease is rare and mainly limited to case reports in the literature. We hereby report a case in which a young patient presented with pericarditis as the first manifestation of Graves' disease.Case summaryA 24-year-old male was admitted to hospital with presenting complaint of left-sided chest pain, gradual in onset, 6/10 in intensity, sharp in character, increased by deep breathing and improved by leaning forward. Patient also gave a history of insomnia, unintentional weight loss despite a good appetite, heat intolerance, and anxiety. On clinical examination, the patient had features of thyrotoxicosis, i.e., tachycardia, high volume pulse, and sweaty palms with fine tremors. There was no associated pericardial rub. Neck examination shows diffuse, non-tender goitre. Electrocardiogram findings were consistent with acute pericarditis. His thyroid function tests demonstrated hyperthyroidism and anti-thyroglobulin antibodies were also significantly elevated. Echocardiogram showed preserved left ventricular systolic function and a small global pericardial effusion without any signs of tamponade. He was diagnosed with Graves' disease revealing itself as pericarditis and was started on ibuprofen, beta-blockers, and carbimazole. Patient had marked clinical and biochemical improvement on 3 monthly follow-ups.DiscussionThyro-pericarditis is a rare entity, and limited literature is available regarding this combination. The exact aetiology of Graves associated pericarditis is unknown. There is a possibility of interaction of autoantibodies with receptors on pericardium. Diagnosis is based on a detailed history, clinical examination, supplemented by relevant investigations (elevated free T4 and thyroid receptor antibodies, suppressed thyroid stimulating hormone (TSH) and Imaging via ultrasound). Mainstay of treatment includes non-steroidal anti-inflammatory drugs, beta-blockers, and anti-thyroidal medications.

Project description:IntroductionMassive thymic hyperplasia (MTH) is a very rare entity, with fewer than 20 cases reported in the literature in infancy. Most patients have respiratory symptoms and the enlarged thymus gland occupies one side of the thoracic cavity. Posterolateral thoracotomy or median sternotomy is the main treatment for MTH in infants. We report a case of an infant with MTH in which the enlarged thymus occupied his bilateral thoracic cavity and he underwent video-assisted thoracoscopic surgery (VATS). In addition, we reviewed and summarized the relevant literature.Case reportA 4-month-old boy was admitted to the hospital with no apparent cause of dyspnea for 18 days, with cough and sputum. On examination, the patient was found to have cyanotic lips, diminished breath sounds in both lungs, and a positive three concave sign. There was no fever or ptosis. Preoperative imaging showed large soft tissue shadows in the bilateral thoracic cavity, with basic symmetry between the right and left sides. Tumor markers were within the normal range. Ultrasound-guided fine needle biopsy showed normal thymic structures with no evidence of malignancy. As his symptoms worsened, he eventually underwent unilateral thoracic approach video-assisted thoracoscopic exploratory surgery, during which a large mass occupying the bilateral thoracic cavity was removed in a separate block and part of the thymus in the left lobe was preserved. Pathological examination confirmed true thymic hyperplasia (TTH). No relevant complications occurred at the 2-month postoperative follow-up.ConclusionIn infants, MTH occupying the bilateral thoracic cavity can produce severe respiratory and circulatory symptoms due to occupying effects. Although a definitive preoperative diagnosis is sometimes difficult, after combining computed tomography (CT) and fine needle biopsy to exclude evidence of other malignancies, the enlarged thymus occupying the bilateral thoracic cavity can be resected via VATS. Whether the enlarged thymus occupies the bilateral thoracic cavity and the size of the thymus are not absolute contraindications to thoracoscopic surgery. The method is safe, feasible, and minimally invasive to the patient.