A previously healthy 40-year-old woman presented with one-week history of diffuse urticarial rash to the dermatology ward which was successfully treated with systemic steroids and antihistamine medications. Three weeks prior to admission, treatment with methimazole 10 mg twice daily had been initiated due to a presumptive diagnosis of Grave's thyroiditis. The diagnosis was made in an outpatient clinic according to typical clinical picture, with low TSH level 0.01 MU/L (normal range 0.35-5.5 MU/L) and high T4 level of 59.1 Pmol/L (normal range 10-20 Pmol/L).
On admission the patient had no symptoms suggestive of hyperthyroidism; on physical examination, an extensive urticarial rash was observed on the limbs and trunk. The patient had a blood pressure of 131/60 mm/Hg, temperature of 36. C, respiration rate of 16 breaths/min, and a pulse rate of 83 beats/min. Her hands were warm and displayed resting tremor. Cardiac examination was normal, but jugular venous distention was noted. Lungs were clear to auscultation. There was no peripheral edema. Extra ocular movements were normal. There was no proptosis or periorbital edema. Thyroid gland was not tender, was slightly enlarged, and had a rubbery consistency on palpation.
Laboratory examinations revealed a white blood cell count: 15.5 x 109 cells/millilitre (normal range: 4-10 x 109 cells/millilitre) with 90% neutrophils and hemoglobin was 12.7 g/dL. On the second day of her hospitalization the patient began to complain of worsening abdominal pain. Liver function tests were taken initially on day two and showed mild abnormality in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gama-glutamil transferase (GGT) levels (86, 72, and 88 U/L, resp.). At this time point, methimazole treatment was discontinued. On the third day of the hospitalization enzyme levels were as follows: ALT 270 U/L, AST 430 U/L, and GGT 210 U/L (normal ranges 0-40 U/L for ALT, 0-35 U/L for AST, and 5-36 U/L for GGT). T4 level was 47 Pmol/L (normal range 10-20 Pmol/L) and T3 level was 5.5 Nmol/L (normal range 1.2-3 Nmol/L).
An abdominal ultrasound showed a large amount of ascites. A diagnostic tap showed fluid with a milky white appearance. Triglyceride level was 12.2 mmol/L (1080 mg/dL), and total protein and lactate dehydrogenase (LDH) levels in ascites were 3.3 g/dL and 326 U/L, respectively. Gram stain was negative for bacteria and fluid cultures were negative. Purified protein derivative (PPD) skin test, acid fast stains of peritoneal fluid, and fluid cultures for tuberculosis were all negative. Serologies for hepatitis A virus, hepatitis B virus, and hepatitis C virus were all negative. Serologies for Epstein-Barr virus and Cytomegalovirus were consistent with prior exposure. Abdominal computed tomography (CT) showed peritoneal fluid, an undefined ovarian mass on the right, and no other abnormalities. Liver size and consistency were normal. Vaginal US did not define the mass better. A lymphangiogram showed no anatomical abnormalities of abdominal lymph vessels or nodes. A gynecological exam was normal, including vaginal ultrasound (US) to define the ovarian mass found on CT scan. The ovarian mass represented a corpus luteum most probably. A follow-up abdominal US after four days showed that the peritoneal fluid had disappeared.
In parallel to this workup the patient started developing signs and symptoms of thyrotoxicosis such as rapid atrial fibrillation which was not present before the discontinuation of methimazole, worsening tremor, and moderate pulmonary hypertension diagnosed with echocardiography. Since treatment with other antithyroid drugs was considered dangerous and since treatment with iodine was expected to have influence only after 4-8 weeks, and the patient had severe symptoms, a therapeutic thyroidectomy was performed two months after admission.
After the procedure the patient was free of symptoms and a follow-up echocardiography showed marked improvement in her pulmonary hypertension. After 1 year of follow-up the patient was asymptomatic, without pulmonary hypertension and with no peritoneal fluid.