52-year-old female with past medical history of intentional 60-pound weight loss over 8 months using a weight loss supplementation system, presented to the emergency department with new onset palpitations, dizziness and shortness of breath. Initial evaluation revealed atrial fibrillation with RVR, normocytic normochromic anemia, elevated alkaline phosphatase and extremely low HDL and LDL, 28 mg/dl and 33 mg/dl respectively with troponinemia of 0.13 ng/ml. TTE results revealed moderate pulmonary hypertension (PHTN) with a RVSP of 58 mmHg and significant left and right sided valvular disease. Further evaluation for PHTN was ordered, and ANA, Anti-SCL 70, V/Q scan, PFTs and Chest CT were normal.
Additional investigation of the weight loss supplement showed that some products from the supplement’s brand sold in Canada and other countries, have being found to contain a compound called 1,3-dimethylamylamine (DMAA), which has known effects on the cardiovascular system similar to amphetamines and sympathomimetics.
On second hospital day, thyroid panel results demonstrated a TSH <0.006 IU/ml, FreeT4 6.44 ng/dl, T3 5.76 ng/dl, TPO levels elevated 154 IU/ml (range 0-34), normal thyroglobulin levels, markedly elevated thyroid receptor antibodies 52.2 IU/ml (0-1.75 range) as well as thyroid stimulation immunoglobulin TSI 674% (0-139%). A diagnosis of Grave’s disease was made and patient was discharged stable, with B-Blockers, NOACs, and to follow up with an endocrinologist in 1 week to start anti-thyroid medication.
Discussion:
In middle aged female patients who take weight loss supplementation (WLS) and present with new onset atrial fibrillation with PHTN and valvular disease multiple considerations are made. While these manifestations can be attributed to WLS, other findings might surprise the clinician.
Conclusions:
This case presented an intriguing clinical challenge, with multiple potential significant contributing factors to the patient’s clinical manifestations; including, the eight-month use of WLS and newly diagnosed Grave’s disease.
Weight loss supplements can pose unexpected risks. One of those reported is the anoretic drug fenfluramine-phentermine (fen-phen) which was found to cause right and left-sided regurgitant valvular heart disease and PHTN, very similar to our case. Furthermore, literature has shown that in patients with Grave’s disease, the levels of thyroid receptor antibodies correlate with the level of PHTN, which in our patient were markedly elevated. Therefore, in this case we believe that two factors; newly diagnosed Grave’s with elevated levels of autoantibodies and use of a weight loss supplement thought to have a compound known to cause cardiovascular adverse effects, contributed to this patient’s clinical findings. Discontinuation of WLS and initiation of anti thyroid therapy should slow the progression of this patient’s PHTN, but her valvular disease if attributed to WLS will persist.