IJCS | Volume 31, Nº2, March / April 2018

DOI: 10.5935/2359-4802.20170089 190 International Journal of Cardiovascular Sciences. 2018;31(2)190-192 CASE REPORT Mailing Address: Antonio José Lagoeiro Jorge Avenida Marques de Paraná, 303. Postal Code: 24033-900, Centro, Niterói, Rio de Janeiro, RJ – Brazil. E-mail: lagoeiro@cardiol.br; lagoeiro@globo.com SevereMitral RegurgitationbyHyperthyroidismin theAbsenceof LeftVentricular Dilatation Antonio José Lagoeiro Jorge, Wolney de Andrade Martins, Eliza de Almeida Gripp, Breno Macêdo de Almeida, Camila Cezário Rocha Paz Figueroa, Cíntia Lobo Sabino Hospital Universitário Antônio Pedro, Universidade Federal Fluminense (UFF), Niterói, RJ – Brazil Manuscript received December 17, 2016, revised manuscript May 31, 2017, accepted July 17, 2017. Mitral Valve Insufficiency; Hyperthyroidism; Graves’ Disease; Pregnant Women. Keywords Introduction Graves’ disease (GD) is an autoimmune disease and the most common cause of thyrotoxicosis, 1,2 with multisystem involvement, that mainly affects women between 40 and 60 years of age. It is the most prevalent cause of autoimmune hyperthyroidism in pregnancy, 1,2 and it can be distinguished fromgestational thyrotoxicosis due to the presence of diffuse goiter and previous history of hyperthyroidism. 3 Clinical hyperthyroidism occurs in 0.2% of pregnant women. 4 Heart failure (HF) is a rare manifestation of decompensatedGDand it represents adiagnostic challenge due to low clinical suspicion of this etiology. 1 We report a case of a pregnant woman with GD who presented thyrotoxicosis and HF with severe mitral dysfunction towards the end of pregnancy, but without ventricular dilatation. Case Report A 23 year-old female patient, 37 weeks pregnant, with a history of previous GD, under irregular treatment of Propylthiouracil for four years, was admitted into the emergency department due to dry cough and high fever. She was admitted to the maternity section at the hospital for investigation, where a FT4 level of 6.0 mg/dL and a TSH of 0.011 ng/dL were found. She denied previous surgeries, highbloodpressure, diabetesmellitus, rheumatic fever, tuberculosis, illicit drug use, alcoholism or smoking. She progressed to labor and after four days a caesareanwas indicated due to acute fetal distress. She was discharged five days after delivery on Tapazole 20 mg per day and Propranolol 80 mg per day. She was readmitted two days after discharge complaining of tiredness, prostration, orthopnea and paroxysmal nocturnal dyspnea. She was lucid, oriented, emaciated, tachydyspneic with accessory muscleuse, pale (2+/4+), febrile andwithmild tremor of the extremities. Bloodpressure of 150/80mmHg; HR110 bpm; RR 32rpm; axillary temp 101.12°F (38.4°C); exophthalmos and goiter with fibroelastic consistency and no nodulation; regular heart rate, hyperphonetic sound, systolic murmur +++/6 in the mitral focus; fine crackles heard at the lung bases, without edema. Hemoglobin of 7.4 g/dL; 18.800 leukocytes; TSH: 0.034 ng/dL and FT4: 1.92 ng/dL. Chest radiograph showing consolidation of the right hemithorax and pulmonary congestion. A transthoracic echocardiography was performed, which showed preservation of the ventricular cavity size and function,mildly increasedbiatrial sizeandseveremitral valve regurgitation,without structural damage,with eccentric jet. Severemitral regurgitation (MR) was characterizedbyaneccentric jet,whichoccupiedgreater than 40% of the left atrial area. Color Doppler showed prominent holosystolic flow . (Figure 1). An antibiotic was started, furosemide 80 mg/day, methyldopa 750mg/day, propranolol 120mg/day and the tapazole dose was increased to 30 mg/day. On the eighth day of hospitalization, the patient was asymptomatic and a newechocardiography showed expressive regression of mitral regurgitation (Figure 2). The patient was discharged from the hospital asymptomatic, in NYHA functional class I, and clinically stable. Discussion It is reported the case of a pregnant woman, with previous hyperthyroidism without adequate treatment, who presented pulmonary infection and HF associated with severe mitral regurgitation, confirmed