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Complete heart-block in hyperthyroidism following acute infections: A report of six cases with necropsy findings in one case
(‘OXPLETE HEART-ULCKK I,\jU ACUTE INFECTION8 WITH
NEC’ROPHY
IN HYPERTIIYROIDIBM : A REPORT OF HIS FIXDINGS
IN
ONE
FOLLOW(-‘ASKS
t’A8E”
AUSTIN (1. DAYIS, M.D., AND HARRY L. SNITH, 3I.D. ROCTIESTEK. MINX.
T
HE high incidence of irregular cardiac action is oue of the striking fea.tures of hypert~hyroidisitr. The arrhythmia cousists maiuly of auricular fibrillation, however, eit,her paroxysmal or permanent, aud These forms of arrhythmia tlet.0 a less ext,eiit,, of auricular flutter. pent1 on disturbance of auricular contractility. Defective anriculoveiit,ricular conduct,ivity is much less frequent? and complete aurhloventricular dissociation is uucommoii. In a review of the literahre on the etiology of heart-bloc1 C and oil arrhythmia. occnrring wit,11 liyperthyroidism, we could find ouly four reports of complete heart-block ass’ociated with liypertl~yroidisni. Xer14en,11 ill 1582, reported the case of a woman, aged twenty-seven years, who had had cxol~litl~aln~ic goiter for six years, and who had attacks of veutricular standstill of four or five seconds’ duration with convulsive seizures. These attacks had tleveloped eight days followin, 0 an acut,c cold, with sore throat. There also was fever which could not be explaine(l hy the physical findings. The seizures occ~i~~ecl repeatedly 0Yei a periotl of two days, and their cessation was associated with recovery from the arrhytlimia, Ill 1915 tic Vries Reilingh’” rcportetl a case of Casedow ‘8 disease with llPilrtblock and Stokes-Adams syndrome. in which the cardiac action ret,urned to normal within ten days. Damesl~rk,~ iii 1924, in au analysis of the installers of arrhythmia report,etl in a series of 141 casrs of 1iSl’ertliyroidisili, fouutl elrctrocnrtliograI,hic evidence of complctc auriculoventricular tlissociation in t,\ro cases : that of a woman, agetl twent,y-six years. Hlld that of a ulan, aged t~wentynine \-cars. Reports of less severe degrees of defect, in conductiou hare been somewhat more numerous. Iiewis,1’) .iii 1913, referred to ii patient with a history of repeat,4 attacks of rheumatic fever. who hat1 partial heart-block following thyroidectomp for t~xophthalmic goiter, anti. subsequently only prolonged auriculoventricular conduction time. Krumbllaar” noted two cases in which the P-R interval was prolougetl, in a series of fifty-one cases studied. Willius, l’,ootllby and Wilson,” in a st,udy of a series of 298 casw, found one in which there 11~~a.s a I’-R interval of twenty-eight hundredths of a second. 111the stucly made by Dameshek4 in 1924 therr were. bcsidrs tllr tlvo casts of c:oln*F’romthr Divisionof Mcdirinc. ‘rhp Mayo Clinic. x7
,s2
‘1‘111~: .\.\IBI
IIf~~:\li’l’
.lOl’l~S;\l.
84
THE
Sections were taken Sections taken from the node, appeared normal of the wall of the left :Inric~~lo~entricuInr node
from x-arious portiorw of t,he heart for microscopic study. walls of the auricles, and ill t,he region of the sino-auricular nn~l stained \vell. Sections taken from different portions rcntricle appeared normal. %&ions taken through the :md lnmdle (~ont:~h~Pd. especially in the ventricular portiw
I
I
I
I!
AMZERICAN
I
I
I
HEART
1
I
I
JOCRSAL.
I
I
I
I
I
I
I
ret
Fig. 2.--a, Mcrnbranous portion of the interventricular tricular bundle; C, muscular portion nf intcrventricular infiltration (X35).
septum b. auricular venseptum; i. areas of cellular
of the hundlr, and also in adjacent structures, extensive cellular infiltration (Fig. 2). This process consisted of wllular foci composed of numerous polymorphonuclenr loueocytes (Fig. 3). and considerable numbers of small mononuclear cells. Mnn,v tlilated blood vcssrls wre prcscnt. This portion of the nnri~ulovcntriculnr bundlr :md the atl,i:~cent tissues were somcwl;:rt edcm:atous. The cellular infiltration was most marked at, the 6uncture of the mcmlnxwux with the muscular portion of the intcrrcntricular septum. ‘IX2 infiltration cstcnded for a consideral~lc distance down into the intervcntri~~ulnr sc~lbtum. Thcrc wr’e scvcrnl regions of lrucocytic infiltration throughout the K:I I1 of the right Ycnt,ricle.
(“ASK G.-A Roman, aged sixty-three years, came to tlw clinic *June 12. 1929, on account of esopl~thnlmic goiter of two years’ duration. She also had mitral stenosis. She hail rweiwcl digitalis continuously for five months, until the time of her She had congestive heart failure, and the clcctrocardiogram admission to tlw clinic. There was no history gave rvidence uf complctc nuriculuvcntricular dissociation. Administration of digitalis xvas discontinued, or evidence of rtwmt arutc infwtion. August 7 lobectom~ was per and two weeks later conduction time m:rs normal.
THE
88
AbrERICAN
I-IEAR’P
.JOIlRNAI>
the treatment with digitalis is enhanced IQ- t,htb f:ic:t t.llat seven months after occurrence of the auricLlloventricnlar dissociation, conrlucticm time, w-as sli&tlg pdonged at, tlic time lvlieu the 10~~ha1 metabolic ixtc. previously mcntioneil, was determined. hi C’ww 6. alt~lioupli no clinical evidence of intrinsic cardiac injury was present, the age of t,lle patient, made ln~bal~le the sa,meesplawrtioii as ap~~lirs in C’ase5. In (‘ase 6 the patient hat1 taken cli~italis continuollsly for five months prior to examination tile clinic ;lIld n’liei1 iltll~lillistI~~tit~ll of tligitillis was discontinued, t,he heart-block cltwr~ascil ill wvt~i~ity, ;~ltllt>n~h it was not known that it snhitlctl until followiii~ tll~-l~oitlt~c~toi~l~. iIt,
Six cases of exopllt~l~alniic goitw in ~rliioh wniplet~c auriclll~)~,riitricular dissociation occnrretl wew obwrvt~tl at 1’11eXayo ( ‘1init. ‘1’11IY’t of the patients had had acute tonsillitis sliortl,v pwce’tlin~ the olk& OF the arl’hytlimia allcl 011P paticIIt hat1 Ilatl ftbrc>r. 111tllr one fatal case, necropsy revealed a.11il~fli~lllIll;~t oi’$ IwioIl invulviiig tile region of the bundle of His, in whiell WV weir i~bl(~ to demonstrate gram-positive bacteria which wt’ bt~licw~tl to hc cit~hcr tliplncowi or stxeptococci in short, chains. In ills two (:ilws of tlita series in \rliich tlrrelopixent~ of t,lie heart-block wa,s not. assoaiwtetl with acut,e infection, there is reason to believe that the head-block \vas prwipitated l)y the effect of digitalis on a prcvioilsly ilijuwtl iillricnloveiitrienlar hnntllr. In t,liose cases in which acntc infcclion was present, evidence is advanced to indicatca that the lirl’erthr-roitlisil~ prdspostd the patient to tlie development of acde iilfcctioli, aritl ills0 to wconclauy myocardial involvt~incnt w1iit.h wsiiltrd ill the owiwtwi~~t~ of IlPilrl-hlO(tl<. St!itrltlt
REFEREK\‘CES 1.
A11tlrus,
29:
2.
E.
c.:
061,
Heart
Fbilurc
\Yith
11~1~~~rtll~r~,itlislrl,
X(v
York
Boothby, W. M..: Diagnosisand Trctltnlrnt ot’ thta I)isv:tses (:lnnd,
Oxford
Nctl.
pt.
3, 3:
905
r, . Eason
.I. 1\1(~1.
of
the
‘I’h;vroi~l
IO“".
2. Cameron, J. I). S., and Hill, I. G. TG7.: Ilenrt-Block of Two Cases, Edinburgh M. .J. 39: 27, 1!1X. 4. Darneshek, William: The Heart in B~~~c~rtll~roirlis~~~, 4X7,
8t:lt(B
1929.
in Toxic Boston
Goiter: M.
a Report
&’ 8. J.
190:
1934.
John:
Toxic
Goitre
and
Sumc~ (‘olllplic~:rtions,
Edinl,urgh
M.
J.
37:
.?4.
193b.
0. Goodall,
J. X., and Rogers,
Lambert:
The
J~Xectriral
and IIistologicnl 1141, 1!)37. St. T~ouis, 1932, p. 4tij,
Consof Thyrotovic Rlyorarditis, Hrit. hl. d. 7. Jell, sI 9. IO. 11.
Xanifrst:l-
1:
(!. A. : Diseases of the Thyroid Gland, The (‘. V. Mosby Co. Kerr, W. J., and Hensel, G. C.: ‘1’11~ t’ar~liovasculnr Systcvn in Thyroid I)~R~YISP, Arch. Int. Med. 31: 395, 19% Krumhhaar, E. B.: Electrocnrdiogr:?l~llic Ohscw:ltions in Toxic Goitre, AIM. J. M. 8~. 155: 175, 1918. Levvis, Thomas: Ph$sical Signs of 1Zyowrdinl 1nrolwmr~nt, Rrit. M. .T. 1: 484, 1913. Merklen: Accidents aigus le tours d’un goitre esold~thalmiquc dntnnt de six ans ; ti+vre, diarrhek, hypercsthbsir &n6rale, intwmittences prolong6es clu coeur suivies a’aech epileptiformes : gu6riscm des phPnomPnes aigus, Rull. SW. clin. de Par. 5: 53, 1882.
and NcEachcrn, Donald: A Study of the Heart in Hyper12. Rake, Geolbey, thyroidism, AM. H~ar.r J. 8: 19, 1933. Certain Cardiovascular Features of Hyper13. Smith, F. J., and Calvin, L. T.: thyroidism, Ann. Clin. Med. 5: 616, 1 !lt’i. 14. de \rries Rcilingh, .K).: Ecn zcldzsn~~ stoornis in de hartt~crkzxxmheid hij morbus Bnsedowii, Nederl. l’ijdsclhr. v. Gcncesk. 2: 1425 1915. 15. Weller, (1. V., Wanstrom, I?. C.. c;ordon, Harold, and B&er, J. C.: Cardiac Histopatllology in Thyroid Disease. Preliminary Report, AM. HEART J. 8: 8 1931. 10. Whi)tc, P. D., and Bull, J. C.: The Electrocardiogram in Thyroid Disease, Arch. Int. Med. 22: 766, 1918. 17. Willius, F. A., Boothby, W. M., and Wilson, 1). B.: The Heart in Esophthalmic Goiter and Adwomatous Goiter With Hyperthyroidism, Med. Clin. N. Amer. 7: ISB, 19-03. 28. Yater, W. M.: Discussion, Au. HEART J. 8: 144, 1933.
NEC’ROPHY
IN HYPERTIIYROIDIBM : A REPORT OF HIS FIXDINGS
IN
ONE
FOLLOW(-‘ASKS
t’A8E”
AUSTIN (1. DAYIS, M.D., AND HARRY L. SNITH, 3I.D. ROCTIESTEK. MINX.
T
HE high incidence of irregular cardiac action is oue of the striking fea.tures of hypert~hyroidisitr. The arrhythmia cousists maiuly of auricular fibrillation, however, eit,her paroxysmal or permanent, aud These forms of arrhythmia tlet.0 a less ext,eiit,, of auricular flutter. pent1 on disturbance of auricular contractility. Defective anriculoveiit,ricular conduct,ivity is much less frequent? and complete aurhloventricular dissociation is uucommoii. In a review of the literahre on the etiology of heart-bloc1 C and oil arrhythmia. occnrring wit,11 liyperthyroidism, we could find ouly four reports of complete heart-block ass’ociated with liypertl~yroidisni. Xer14en,11 ill 1582, reported the case of a woman, aged twenty-seven years, who had had cxol~litl~aln~ic goiter for six years, and who had attacks of veutricular standstill of four or five seconds’ duration with convulsive seizures. These attacks had tleveloped eight days followin, 0 an acut,c cold, with sore throat. There also was fever which could not be explaine(l hy the physical findings. The seizures occ~i~~ecl repeatedly 0Yei a periotl of two days, and their cessation was associated with recovery from the arrhytlimia, Ill 1915 tic Vries Reilingh’” rcportetl a case of Casedow ‘8 disease with llPilrtblock and Stokes-Adams syndrome. in which the cardiac action ret,urned to normal within ten days. Damesl~rk,~ iii 1924, in au analysis of the installers of arrhythmia report,etl in a series of 141 casrs of 1iSl’ertliyroidisili, fouutl elrctrocnrtliograI,hic evidence of complctc auriculoventricular tlissociation in t,\ro cases : that of a woman, agetl twent,y-six years. Hlld that of a ulan, aged t~wentynine \-cars. Reports of less severe degrees of defect, in conductiou hare been somewhat more numerous. Iiewis,1’) .iii 1913, referred to ii patient with a history of repeat,4 attacks of rheumatic fever. who hat1 partial heart-block following thyroidectomp for t~xophthalmic goiter, anti. subsequently only prolonged auriculoventricular conduction time. Krumbllaar” noted two cases in which the P-R interval was prolougetl, in a series of fifty-one cases studied. Willius, l’,ootllby and Wilson,” in a st,udy of a series of 298 casw, found one in which there 11~~a.s a I’-R interval of twenty-eight hundredths of a second. 111the stucly made by Dameshek4 in 1924 therr were. bcsidrs tllr tlvo casts of c:oln*F’romthr Divisionof Mcdirinc. ‘rhp Mayo Clinic. x7
,s2
‘1‘111~: .\.\IBI
IIf~~:\li’l’
.lOl’l~S;\l.
84
THE
Sections were taken Sections taken from the node, appeared normal of the wall of the left :Inric~~lo~entricuInr node
from x-arious portiorw of t,he heart for microscopic study. walls of the auricles, and ill t,he region of the sino-auricular nn~l stained \vell. Sections taken from different portions rcntricle appeared normal. %&ions taken through the :md lnmdle (~ont:~h~Pd. especially in the ventricular portiw
I
I
I
I!
AMZERICAN
I
I
I
HEART
1
I
I
JOCRSAL.
I
I
I
I
I
I
I
ret
Fig. 2.--a, Mcrnbranous portion of the interventricular tricular bundle; C, muscular portion nf intcrventricular infiltration (X35).
septum b. auricular venseptum; i. areas of cellular
of the hundlr, and also in adjacent structures, extensive cellular infiltration (Fig. 2). This process consisted of wllular foci composed of numerous polymorphonuclenr loueocytes (Fig. 3). and considerable numbers of small mononuclear cells. Mnn,v tlilated blood vcssrls wre prcscnt. This portion of the nnri~ulovcntriculnr bundlr :md the atl,i:~cent tissues were somcwl;:rt edcm:atous. The cellular infiltration was most marked at, the 6uncture of the mcmlnxwux with the muscular portion of the intcrrcntricular septum. ‘IX2 infiltration cstcnded for a consideral~lc distance down into the intervcntri~~ulnr sc~lbtum. Thcrc wr’e scvcrnl regions of lrucocytic infiltration throughout the K:I I1 of the right Ycnt,ricle.
(“ASK G.-A Roman, aged sixty-three years, came to tlw clinic *June 12. 1929, on account of esopl~thnlmic goiter of two years’ duration. She also had mitral stenosis. She hail rweiwcl digitalis continuously for five months, until the time of her She had congestive heart failure, and the clcctrocardiogram admission to tlw clinic. There was no history gave rvidence uf complctc nuriculuvcntricular dissociation. Administration of digitalis xvas discontinued, or evidence of rtwmt arutc infwtion. August 7 lobectom~ was per and two weeks later conduction time m:rs normal.
THE
88
AbrERICAN
I-IEAR’P
.JOIlRNAI>
the treatment with digitalis is enhanced IQ- t,htb f:ic:t t.llat seven months after occurrence of the auricLlloventricnlar dissociation, conrlucticm time, w-as sli&tlg pdonged at, tlic time lvlieu the 10~~ha1 metabolic ixtc. previously mcntioneil, was determined. hi C’ww 6. alt~lioupli no clinical evidence of intrinsic cardiac injury was present, the age of t,lle patient, made ln~bal~le the sa,meesplawrtioii as ap~~lirs in C’ase5. In (‘ase 6 the patient hat1 taken cli~italis continuollsly for five months prior to examination tile clinic ;lIld n’liei1 iltll~lillistI~~tit~ll of tligitillis was discontinued, t,he heart-block cltwr~ascil ill wvt~i~ity, ;~ltllt>n~h it was not known that it snhitlctl until followiii~ tll~-l~oitlt~c~toi~l~. iIt,
Six cases of exopllt~l~alniic goitw in ~rliioh wniplet~c auriclll~)~,riitricular dissociation occnrretl wew obwrvt~tl at 1’11eXayo ( ‘1init. ‘1’11IY’t of the patients had had acute tonsillitis sliortl,v pwce’tlin~ the olk& OF the arl’hytlimia allcl 011P paticIIt hat1 Ilatl ftbrc>r. 111tllr one fatal case, necropsy revealed a.11il~fli~lllIll;~t oi’$ IwioIl invulviiig tile region of the bundle of His, in whiell WV weir i~bl(~ to demonstrate gram-positive bacteria which wt’ bt~licw~tl to hc cit~hcr tliplncowi or stxeptococci in short, chains. In ills two (:ilws of tlita series in \rliich tlrrelopixent~ of t,lie heart-block wa,s not. assoaiwtetl with acut,e infection, there is reason to believe that the head-block \vas prwipitated l)y the effect of digitalis on a prcvioilsly ilijuwtl iillricnloveiitrienlar hnntllr. In t,liose cases in which acntc infcclion was present, evidence is advanced to indicatca that the lirl’erthr-roitlisil~ prdspostd the patient to tlie development of acde iilfcctioli, aritl ills0 to wconclauy myocardial involvt~incnt w1iit.h wsiiltrd ill the owiwtwi~~t~ of IlPilrl-hlO(tl<. St!itrltlt
REFEREK\‘CES 1.
A11tlrus,
29:
2.
E.
c.:
061,
Heart
Fbilurc
\Yith
11~1~~~rtll~r~,itlislrl,
X(v
York
Boothby, W. M..: Diagnosisand Trctltnlrnt ot’ thta I)isv:tses (:lnnd,
Oxford
Nctl.
pt.
3, 3:
905
r, . Eason
.I. 1\1(~1.
of
the
‘I’h;vroi~l
IO“".
2. Cameron, J. I). S., and Hill, I. G. TG7.: Ilenrt-Block of Two Cases, Edinburgh M. .J. 39: 27, 1!1X. 4. Darneshek, William: The Heart in B~~~c~rtll~roirlis~~~, 4X7,
8t:lt(B
1929.
in Toxic Boston
Goiter: M.
a Report
&’ 8. J.
190:
1934.
John:
Toxic
Goitre
and
Sumc~ (‘olllplic~:rtions,
Edinl,urgh
M.
J.
37:
.?4.
193b.
0. Goodall,
J. X., and Rogers,
Lambert:
The
J~Xectriral
and IIistologicnl 1141, 1!)37. St. T~ouis, 1932, p. 4tij,
Consof Thyrotovic Rlyorarditis, Hrit. hl. d. 7. Jell, sI 9. IO. 11.
Xanifrst:l-
1:
(!. A. : Diseases of the Thyroid Gland, The (‘. V. Mosby Co. Kerr, W. J., and Hensel, G. C.: ‘1’11~ t’ar~liovasculnr Systcvn in Thyroid I)~R~YISP, Arch. Int. Med. 31: 395, 19% Krumhhaar, E. B.: Electrocnrdiogr:?l~llic Ohscw:ltions in Toxic Goitre, AIM. J. M. 8~. 155: 175, 1918. Levvis, Thomas: Ph$sical Signs of 1Zyowrdinl 1nrolwmr~nt, Rrit. M. .T. 1: 484, 1913. Merklen: Accidents aigus le tours d’un goitre esold~thalmiquc dntnnt de six ans ; ti+vre, diarrhek, hypercsthbsir &n6rale, intwmittences prolong6es clu coeur suivies a’aech epileptiformes : gu6riscm des phPnomPnes aigus, Rull. SW. clin. de Par. 5: 53, 1882.
and NcEachcrn, Donald: A Study of the Heart in Hyper12. Rake, Geolbey, thyroidism, AM. H~ar.r J. 8: 19, 1933. Certain Cardiovascular Features of Hyper13. Smith, F. J., and Calvin, L. T.: thyroidism, Ann. Clin. Med. 5: 616, 1 !lt’i. 14. de \rries Rcilingh, .K).: Ecn zcldzsn~~ stoornis in de hartt~crkzxxmheid hij morbus Bnsedowii, Nederl. l’ijdsclhr. v. Gcncesk. 2: 1425 1915. 15. Weller, (1. V., Wanstrom, I?. C.. c;ordon, Harold, and B&er, J. C.: Cardiac Histopatllology in Thyroid Disease. Preliminary Report, AM. HEART J. 8: 8 1931. 10. Whi)tc, P. D., and Bull, J. C.: The Electrocardiogram in Thyroid Disease, Arch. Int. Med. 22: 766, 1918. 17. Willius, F. A., Boothby, W. M., and Wilson, 1). B.: The Heart in Esophthalmic Goiter and Adwomatous Goiter With Hyperthyroidism, Med. Clin. N. Amer. 7: ISB, 19-03. 28. Yater, W. M.: Discussion, Au. HEART J. 8: 144, 1933.