1. A 40-year-old man presented with cough, swelling of the lower limbs and abdomen, and shortness of breath. Examination found signs of right heart failure and rapid atrial fibrillation. 2. Further history revealed symptoms of hyperthyroidism. Tests confirmed Graves' disease. 3. The patient's pulmonary hypertension and right heart failure were found to be caused by severe thyrotoxicosis, a reversible condition if treated. Studies show up to 47% of patients with hyperthyroidism can develop pulmonary hypertension.

1. Case presentation by Dr Tariq Alrashidi B1 unit

2. 40 yrs old philipino man admitted with 1 month H/O dray cough exertional dyspnia , progressive lower limbs and abdominal wall edema , ?H/O of fever on and off .2 weeks before admission started to have palpitation ,one week before admission the swelling of lower limbs increase and the short of breath become s with minimal efforts later become at rest .On the day of admission pt developed severe dyspnia and palpitation . NO H/O chest pain ,no loose motion ,no drug history ,no significant illness or surgical procedure in the past. Later on (after pt sablized) he gave H/O ???

3. Any Q REGARDING HISTORY?

4. O/E pt conscious, oriented but in respiratory distress BP140/80, HR 200 (AF) , TEMP 39, O2 SAT ON OXYGEN MASK 100% CONGESTED NECK VEINS , MILD SMOTH SOFT S w ELLING ON ANTERIOR ASPECT OF THE NECK . LOWER LIMBS ,SACRAL AND SCROTAL EDEMA PRESENT

5. CHEST : DULNESS OVER THE RT LUNG ON PERCUTION ,DECREASE AIR ENTRY ON THE RT UPTO 2/3 OF THE LUNG, INSPIRSTORY AND EXPIRATORY CREPITATION ALL OVER THE LT LUNG. HEART : VARIABLE S1 NORMAL S2 NO MURMUR OR ADD SOUND CAN BE HEARED DUE TO RAPID AF. ABD : SOFT LAX ,SHIFTING DULLNESS POSTIVE CNS: INTACT .

6. WHAT IS THE DDx?

8. ADMISION DX WAS RT HF AND RAPID AF WITH CHEST INFECTION. RX LASIX 40 IV DIGOXIN 1MG GIVEN IN RR CAPOTEN 6.25 MG CLEAXINE S/C

9. INVESTIGATION

12. ABG : ph 7.30 pco2 5.6 po2 5.2 hco3 20 o2 sat 67

16. CT CHEST WITH ANGI .. NEGATIVE FOR PULMONARY EMBOLISM U/S ABD NORMAL

18. ECHO (21/5/2009): NORMAL LV SYSTOLIC FUNCTION EF 60% NO RWMA MILD TO MODERAT MR AND LA DILATATION RT SIDE DILATATION, MILD PA DILATATION , MILD TR , MOD TO SEVERE PHT (69)

19. PLUERAL TAPPING DONE

21. BY REQESTIONING THE PT LATER HE GAVE H/O 6 months of wt loss ( 20kg in 6 month ) , increase appetite , nervousness and easy loosing his temper,insomenia and heat intolarence.

22. TFT (0n 20/5/2009): TSH 0.01 FT4 70.56

28. FINAL DX S EVERE THYROTOXICOSIS LEADS TO AF AND PULMONARY HYPERTENSION AND RT HF WITH RT SIDE MASSIVE PLUERAL EFFUSION AND RT SIDE LUNG COLLAPSE

29. PULMONARY HYPERTENSION IN MEN WITH THYROTOXICOSIS CASE REPORT (RESPIRATION JORNAL 2005;72:90-94)

30. CASE 1 41 YRS MAN PREVIOUSLY HEALTHY, PRESENTED WITH PALPITATION,DIAPHORESIS DYSPNIA ,BLURED VISION,WT LOS. O/E PROPTOSIS,LID LAG DIFFUSLY ENLARGED THYRIOD. CARDIO PULMONARY EXAM NORMAL. I NVESTIGATION CXR PROMINENT VASCULAR MARKING TSH <0.05 MN/ML , FT 49.18ng/dl THYROID SCAN CONSIST WITH GRAVE’S DISEASE PFT ..MILD RESTRICTIVE PATTERN ECHO … DILATED LA , RA AND RV , BUT NORMAL LV , SPAP 57 mmhg . CT PULMONARY ANGIO NEGATIVE FOR PE , COLLAGEN SCREENING NEGATIVE , AND OTHER 2NDRY CAUSES FOR PHT NEGATIVE apt given propylthiouracil,propranolol later treated with radioactive iodine 9MONTHS LATER ECHO DONE SYST PAP36 MMHG WITH RESOLUTION OF RA AND RV DILATATION AND NORMAL LV.

31. CASE 2 68 YRS MALE WITH PEPTIC ULCER ,OA KNEE PRESENT WITH TREMOR, BLURRED VISION, EXERTIONAL DYSPNIA , WIEGHT LOS OVER 3 MONTHS. O/E LID LAG,TREMOR,THYROMEGALY, NORMAL CARDIOPULMONARY EXAM. INVESTIGATION TSH 0.05 mu/ml, FT4 3.66 ng/dl . THYRIOD SCAN …GRAVE’S DISEASE, ANTI MICROS AB POSTIVE CXR.. NORMAL PFT.. MILD OBSTRUCTIVE PATTERN ECHO… PAP 52 mmhg , DILATED RA,RV AND NORMAL LV. V/Q SCAN NEGATIVE PT NEGATIVE FOR OTHER 2NDRY CUASES OF PHT. PATIENT GIVEN RAI AND BECOMES ASYMPTOMATIC ECHO DONE 2 YRS LATER …SYST PAP 32 mmhgWITH NORMALIZED CARDIAC CHAMBERS

32. Case 3 59yrs male h/o htn presented heat intoierance, tremor, diahria,weakness ,palpitation,wt loss over 4 month. O/E SMOOTH VELVETY SKIN , LID LAG , EXOPH , THYROMEGALY , RT VENTRICULAR HEAVE , AF. INVESTIGATION TSH 0.11 UM/ML , FT4 51.08 , ANTI MICRISM +VE , ANTI THYROGLOBULIN NEGATIVE. CXR NORMAL , PFT MILD OBST , NO EVEDANCE OF THROMBOEMBOLIC DISEASE. ECHO : SEVERE TR , SPAP 51 MMHG, RA AND RV DILATATION WITH NORMAL LV . OTHER 2NDRY CUASES OF PHT NEGATIVE. RX PT GIVEN PROPNALOL , DIGOXIN AND WARFARIN TO CONTROL HR , ANTI HYPERTHYROIDISM ( PTU ) LATER RAI THERAPY. REPATED ECHO 2 YRS LATER REVEALED SPAP 34 MMHG RESOLUTION OF OTHER CARDIAC ABNORMALITY .

34. STUDY PUPLESHED IN JORNAL OF CLINICAL ENDOCRINOLOGY AND METABOLISM 2006 THEY PREFORMED SERIAL ECHO CARDIOGRAPHY EXAMINATIONS ON 75 COSECUTIVE PATIENTS WITH HYPERTHYROIDISM(43+-2 YRS, 47 WOMEN) TO ESTIMATE PULMONARY ARTERY SYSTOLIC PRESSURE (PASP) , CARDIAC OUTPUT(CO) , TOTAL VASCULAR RESISTANCE (TVR) , LEFT VENTRICULAR FILLING PRESSURE .EXAMINATION PREFORMED AT BASE LINE AND 6 MONTHS AFTER INITIATION OF ANTITHYROID RX .RESULT WERE COMPARED WITH 35 AGE –SEX- MATCHED HEALTY CONTROLS.

35. CONCLUSION IN PATIENTS WITH HYPERTHYRIODISM AND NORMAL LV SYSTOLIC FUNCTION ,UPTO 47% HAD PHT DUE TO EITHER PAH WITH INCREASE CO (70%) OR PVH WITH ELEVATED LV FILLING PRESSURE (30%). MOST IMPORTANTLY HYPERTHYRIODISM –RELATED PHT WAS LARGELY ASYMPTOMATIC AND REVERSIBLE AFTER RESTORATION TO EUTHYROID STATE.

36. FINALY T HESE CASES SUPPORT FOR HYPERTHYROIDISM AS 2NDRY CAUSE OF PHT .IT IS IMPORTANT TO RECOGNIZE THIS ASSOCIATION SINCE IT IS REVERSIBLE And THEREFORE T REATABLE CUASE OF PHT . I T IS RECOMMENDED THAT ALL PATIENTS WITH DIAGNOSIS OF IDIOPATHIC HF BE EXAMINED FOR TFT IN ORDER TO IDENTIFY HYPERTHYROID SUBJECTS WITH REVERSIBLE MYOCARDIAL DYSFUNCTION.

37. THANK U