Graves' Disease with Intractable Diarrhea, Chylous Ascites, and Chylothorax: A Case Report

Abstract

A 50-year-old woman was admitted to our hospital because of severe diarrhea, irritableness, and severe pitting edema of the legs. The patient had been well until 5 years before admission, when a tremor and tachycardia developed and a diagnosis of Graves' disease was made. Treatment with methimazole was effective in reducing her tremor and tachycardia; however, she was often nonadherent with her antithyroid medication because of improvement of her symptoms. On admission, a thyroid swelling, exophthalmos, a pleural effusion, and ascites were observed. The results of thyroid function tests (free triiodothyronine: 21.5 pg/mL; free thyroxine: 7.17 ng/dL; thyroid-stimulating hormone (TSH): <0.01 microIU/mL; TSH receptor antibodies: 95.9%) were consistent with Graves' disease. Biochemical analysis of pleural and ascitic fluid was consistent with chylothorax and chylous ascites, respectively. Serum calcium, total protein, and albumin were very low. Her symptoms and signs except severe diarrhea, edema, pleural effusion, and ascites disappeared after receiving intravenous drip infusion of fluid replacement, and methimazole and iodine. Because of malnutrition, she was given a high-calorie intravenous infusion. Three months after admission, her pleural effusion and ascites began to improve, as did her diarrhea and hypoalbuminemia. An appropriate treatment of Graves' disease is crucial to avoid serious sequelae of longstanding, poorly controlled hyperthyroidism.

Chylothorax Associated with Substernal Goiter in Graves’ Disease Treated with Radioactive Iodine

“…In another case, the patient was treated with 131I but therapeutic effect of radioiodine was unknown because the patient died ( 13 ). In the other case, patient was improved by treatment of underlying disease with methimazole, iodine and conservative therapy after 3 month ( 3 ).…”

“…In association with thyroid disease, traumatic chylothorax has occasionally been reported after neck dissection for thyroid cancer surgery ( 6 - 8 ). However, nontraumatic chylothorax associated with a substernal goiter has been reported rarely ( 3 , 4 , 13 ). A possible mechanism of chylothorax is external compression of the thoracic duct along its course ( 6 ).…”

“…In chylothorax cases associated with goiter other than traumatic chylothorax due to thyroid surgery, therapeutic options include anti-thyroid drugs ( 3 ), transcervical thyroidectomy ( 4 ), and 131I therapy ( 13 ). There is no preferred therapy for chylothorax caused by a retrosternal goiter in Graves’ disease.…”

“…Rarely, a substernal nontoxic goiter can cause venous compression of the mediastinal structures, including superior vena cava syndrome ( 2 ). Nevertheless, chylothorax in Graves’ disease caused by a substernal goiter or a nontoxic substernal goiter is very rare ( 3 , 4 ).…”

Chylous Ascites: A Rare Adverse Effect of Methimazole Treatment for Grave’s Disease—A Case Report and Review of the Literature

“…Among the unique features are ophthalmopathy and infiltrative dermopathy [ 2 ]. In addition, rare manifestations of Grave's disease have been described, including pulmonary hypertension and chylous ascites, for which we found only one case reported in the literature [ 3 ].…”