J Korean Endocr Soc.  2008 Oct;23(5):332-336. 10.3803/jkes.2008.23.5.332.

A Patient with Primary Amyloidosis Misrecognized as Thyrotoxicosis-induced Heart Failure

• Lee SJ
• Lee SH
• Chin JY
• Song YM
• Lee SW
• Kim MH
• Kang MJ
• Lee KW
• Kwon HS
• Yoon KH
• Son HY
• Cha BY

• KMID: 1479226
• DOI: http://doi.org/10.3803/jkes.2008.23.5.332

Abstract

Amyloidosis is caused by deposition of insoluble amyloid protein in the extracellular space of organs and tissues. The causes of amyloidosis are classified as primary, secondary, and hereditary, and symptoms develop according to which organ is involved. Cardiac amyloidosis induces cardiomyopathy and is developed by deposition of amyloid proteins in cardiac tissue. We diagnosed a patient with rhabdomyolysis and thyrotoxicosis with underlying Graves' disease 5 years ago. The patient was readmitted recently complaining of general weakness and mild dyspnea, and was diagnosed as relapsed thyrotoxicosis. An echocardiogram was performed for the evaluation of dyspnea and the findings were compatible with infiltrative cardiomyopathy due to amyloidosis. A biopsy of the abdominal subcutaneous fat and rectal mucosa was performed, and diagnosis was amyloidosis with histologic findings. The cause of heart failure was therefore cardiac amyloidosis rather than thyrotoxicosis. This case indicates the importance of evaluating the cause of heart failure in patients with thyrotoxicosis.

Keyword

cardiac amyloidosis; Graves' disease; heart failure; thyrotoxicosis

MeSH Terms

Amyloid
Amyloidogenic Proteins
Amyloidosis
Biopsy
Cardiomyopathies
Dyspnea
Extracellular Space
Graves Disease
Heart
Heart Failure
Humans
Mucous Membrane
Rhabdomyolysis
Subcutaneous Fat, Abdominal
Thyrotoxicosis
Amyloid
Amyloidogenic Proteins
Amyloidosis

Figure

• 

  Fig. 1 Thyroid function test during 5years follow-up.

• 

  Fig. 2 99mTc scan of thyroid gland shows multiple cold nodules in both thyroid gland.

• 

  Fig. 3 Parasternal long-axis view of echocardiography shows mild left ventricular thickening and increased echogenicity of the myocardium (granular sparkling, arrow).

• 

  Fig. 4 Focal amyloid infiltration of the subcutaneous fat forms an apple-green birefringence under polarizing microscopy (Congo-red stain, original magnification, ×200).

Reference

1. Glenner GG. Amyloid deposits and amyloidosis. The beta-fibrilloses. N Engl J Med. 1980. 302:1283–1292.

2. Falk RH. Diagnosis and management of the cardiac amyloidoses. Circulation. 2005. 112:2047–2060.

3. Sanchorawala V. Light-chain(AL) amyloidosis: diagnosis × treatment. Clin J Am Soc Nephrol. 2006. 1:1331–1341.

4. Hong SB, Kim MS, Lee KW, Kim MR, In HH, Kim KR, Cho YU, Joo YC. Graves' disease associated with Hashimoto's thyroiditis. J Kor Soc Endocrinol. 1996. 11:182–188.

5. Siu SW, Yeung CY, Lau CP, Kung AWC, Tse HF. Incidence, clinical characteristics and outcome of congestive heart failure as the initial presentation in patients with primary hyperthyroidism. Heart. 2007. 93:483–487.

6. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med. 2001. 344:501–509.

7. Klein I, Ojamaa K. Thyrotoxicosis and the heart. Endocrinol Metab Clin North Am. 1998. 27:51–62.

8. Levey GS, Klein I. Catecholamine-thyroid hormone interaction and the cardiovascular manifestation of hyperthyroidism. Am J Med. 1990. 88:642–646.

9. Choudhury RP, MacDermot J. Heart failure in thyrotoxicosis, an approach to management. Br J Clin Pharmacol. 1998. 46:421–424.

10. Hassan W, Al-Sergani H, Mourad W, Tabbaa R. Amyloid heart disease. New frontiers and insights in pathophysiology, diagnosis, and management. Tex Heart Inst J. 2005. 32:178–184.

11. van Rijswijk MH, van Heusden CW. The potassium permanganate method. A reliable method for differentiating amyloid AA from other forms of amyloid in routine laboratory practice. Am J Pathol. 1979. 97:43–58.

12. Shenfield GM, Thompson J, Horn DB. Plasma and urinary digoxin in thyroid dysfunction. Eur J Pharmacol. 1977. 12:437–443.

13. Pollak A, Falk RH. Left ventricular systolic dysfunction precipitated by verapamil in cardiac amyloidosis. Chest. 1993. 104:618–620.

14. de Saedeleer B, Poppe K, Lacor P, de Mey J, Vincken W, Bourgain C, Velkeiniers B. Toxic intrathoracic goiter and mediastinal lymphadenopathy: an unusual presentation of systemic primary AL amyloidosis. Acta Clin Belg. 2003. 58:46–49.

15. Ikenoue H, Okamura K, Kuroda T, Sato K, Yoshinari M, Fujishima M. Thyroid amyloidosis with recurrent subacute thyroiditis-like syndrome. J Clin Endocrinol Metab. 1988. 67:41–45.