Endocrine Abstracts

Introduction: Chronic longstanding hypothyroidism is a known cause of pericardial effusion. However, cardiac tamponade as the primary presentation of Hashimoto’s hypothyroidism is relatively uncommon.

Case description: A 34-year-old African American woman presented to the ER complaining of shortness of breath, fever, cough and precordial chest pain of 1 day duration. Examination revealed an obese female with patchy alopecia and dry skin in mild respiratory distress. Further examination revealed tachycardia, raised JVD and pulsus paradoxus. Chest radiograph showed marked cardiomegaly. ECG revealed sinus tachycardia at 80 bpm, and reduced QRS voltage. Echocardiography demonstrated a large pericardial effusion and diastolic RV collapse consistent with cardiac tamponade physiology. Pericardial window was performed and a total of 1500 ml of serous fluid was drained. Pericardial fluid culture, cytology and pericardial biopsy were performed and analysis returned as exudative fluid. All causes of massive pericardial effusion including infection, neoplasm, trauma, uremia, post-acute myocardial effusion or aortic dissection were ruled out. Patient’s TSH level returned as 65.8 μIU/ml and a subsequent thyroid antimicrosomal antibody level of >600 IU/ml lead to a diagnosis of Hashimoto’s thyroiditis. Replacement thyroid therapy was initiated with levothyroxine 0.05 mg/day and empiric antibiotics were discontinued. Subsequently, the patient became asymptomatic and was discharged for follow-up as outpatient. On follow-up her TSH levels have been therapeutic and no signs/symptoms of recurrent effusion are evident till date.

Conclusion: Cardiac tamponade is an uncommon presentation or complication of hypothyroidism requiring a high index of suspicion and timely intervention. Treatment with pericardial window may be essential and long term levothyroxine therapy with follow up is imperative in such cases.