Key words: Graves’diease,myocarditis,thyrotoxic periodic paralysis,junctional tachycardia.

Key clnical message:

Physicians should not ignore Graves’ disease when facing patients unknown paralysis.Physicians should know acute myocarditis is a rare combination of Graves’ disease which etiology may contribute to autoimmunity.

1 Introduction:

We report a case of acute myocarditis and thyrotoxic periodic paralysis in the setting of new-onset Graves’ disease. A previously healthy 25-year-old male presented with sudden paralysis,palpitations,dyspnea,elevated troponin I and extremehypokalemia.After thorough examination he was diagnosed with Graves’ disease combined with acute myocarditis and thyroxic periodic paralysis.

2 Case report

.Graves’ disease is an autoimmune disorder that affects the thyroid gland^[1]. Hyperthyroidism affects 0.5%-2% of females^[2] in geographical areas not featuring iodine deficiency. Males show a 10-fold lower prevalence. Graves’ disease is the most frequent cause and is more likely to occur in female populations^[2]. Graves’ disease would seem to be more frequent in Asian populations and less frequent in sub-Saharan Africans^[2]. Thyroid hormone (TH) receptors are present in the myocardium and vascular endothelial tissues, thereby allowing changes in circulating TH concentration to modulate end-organ activity^[3]. Thus, Graves’ disease can present with cardiovascular manifestations. Usually misdiagnosed as myocardial infarction, Graves’ disease combined with acute myocarditis is a rare manifestation, and the etiology is due to an autoimmune process.

When the electrical activity of the sinoatrial node is blocked or is less than the automaticity of the atrioventricular node/His bundle, a junctional rhythm originates^[4]. Numerous conditions can cause a junctional rhythm, among which myocarditis is a rare etiology^[4]. Acute myocarditis should be diagnosed when several differential diagnoses are excluded, such as tachycardiomyopathy (TCMP), stress cardiomyopathy, and pericardial diseases. Acute myocarditis presents with junctional arrhythmia is reported in children and seldomly reported in adults. There have been a few reports about Graves’ disease combined with acute myocarditis^[5-7]. However, the patient’s manifestations differ in these cases. None of these cases presents with junctional arrhythmia. In this case, the patient presented with an accelerated junctional rhythm and myocarditis, which is unique compared with other reported cases, so that clinicians can have a new understanding of the cardiovascular complications of Graves’ disease.