Primary Hypothyroidism Leading to Massive Pericardial Effusion and Diastolic Right Ventricular Compression: a Case Report
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Although hypothyroidism with primary etiology could cause small pericardial effusion, massive one leading to cardiac tamponade and ventricular diastolic compression is rare and less reported in the literature. Here we described a patient with severe primary hypothyroidism leading to pericardial effusion and right ventricular compression. A 56-year-old diabetic man referred to the emergency department complaining of dyspnea worsening over the prior month. Further evaluations including electrocardiography, chest X-ray, and echocardiography plus laboratory data were requested. Para-clinic data revealed massive pericardial effusion in the presence of primary hypothyroidism. Pericardiocentesis was performed due to his severe symptoms which symptoms improvement were considerably achieved. Despite its rareness, hypothyroidism should be kept in mind whenever evaluating patients with massive pericardial effusion, especially after exclusion of other more common etiologies.
KeywordsHypothyroidism Pericardial effusion Levothyroxine Pericardiocentesis
Although cardiac manifestations of hypothyroidism, including bradycardia and pericardial effusion (PE) are common, massive pericardial effusion or pericardial tamponade is rarely reported . Hypothyroidism is infrequently presented primarily by pericardial effusion, but the most common cardiac manifestation which could happen in patients suffering from severe hypothyroidism would be bradycardia and pericardial effusion . Cardiac tamponade leading to right ventricular (RV) and right atrial (RA) compression happens extremely rare . Here, in this paper, we described a patient with right ventricular (RV) collapse as the first presentation of severe primary hypothyroidism.
A 56-year-old Iranian male presented to our emergency department with worsening of dyspnea associated with weakness, fatigue, slow speech, and periorbital edema since last month before his admission. He also complained of orthopnea. His medical history was unremarkable except for smoking one packet of cigarette daily for 10 years (10 packs/year) and type two diabetes mellitus diagnosed 10 years earlier.
Here, we presented a patient suffering from massive pericardial effusion leading to cardiac tamponade due to severe primary hypothyroidism confirmed by clinical and laboratory findings.
The prevalence of this condition in patients with severe and mild hypothyroidism was estimated to be 20–30% and 3–6%, respectively . PE and cardiac tamponade are among two of the rarest manifestations of hypothyroidism . Parving et al. believed that it is caused by a combination of albumin extravasation and slow lymphatic drainage . In another study, the molecular mechanism of the effect of triiodothyronine (T3) in cardiac cells was responsible. After binding T3 to its nuclear receptors, expression of some genes including alpha-myosin heavy chain, beta-1 adrenergic receptor, voltage-gated potassium channels, and sarcoplasmic reticulum calcium ATPase would be changed. Many cardiac manifestations are considered to be related to those gene expression alterations . Diagnosis of cardiac tamponade in hypothyroidism is difficult and almost mistaken for heart failure because of several nonspecific symptoms including tachypnea, lower limb edema, and increased venous pressure . Beck’s triad components, including increased jugular venous pressure, hypotension, and diminished heart sounds, define cardiac tamponade. From non-invasive para-clinic tools, the gold standard way to confirm the diagnosis is TTE, which is optimal for assessing the severity of effusion and compressive effects on the heart chamber . ECG findings include low-voltage QRS complexes, ST segment deviation, PR segment depression, and T wave changes . In patients suffering uremia or hypothyroidism, bradycardia may be the only cardiac manifestation . Even if the definite diagnosis of hypothyroidism was made, other etiologies must be kept in mind because this relationship is commonly rare and other pathophysiological mechanisms need more aggressive and different management strategies .
While some scientists prefer immediate surgical approaches to make pericardial window initially to prevent symptom recurrence, others believe in the individualization of therapy. For instance, in case of mild hemodynamic alteration, conservative management including close monitoring, performing serial ECGs and avoidance of volume depletion should have been done. In patients with pulsus paradoxus or recurrent PE, pericardiocentesis or pericardial window, respectively, would be the right management strategies .
The base of hypothyroidism treatment is thyroxin replacement therapy. It is usually started with low dose thyroxin (25 mcg/day), especially in older people to prevent complications like atrial fibrillation and worsening coronary heart diseases and will gradually increase to higher dosages . After initiation of therapy, pericardial effusion will resolve gradually, and as patients gain euthyroid level, effusion would be entirely resolved. Our patient, because of poor compliance with drug usage, returned to the hospital with massive pericardial effusion within few months .
In conclusion, it is reasonable that on a routine evaluation of massive pericardial effusion after excluding common causes such as malignancies, infections, and connective tissue disorders, hypothyroidism should be kept in mind and appropriate diagnostic and therapeutic management must have been performed.
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Conflict of Interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
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