Early Cardiac Tamponade in a Patient with Postsurgical Hypothyroidism

Abstract

Pericardial effusion is a common cardiac manifestation of hypothyroidism, but effusion resulting in cardiac tamponade is extremely rare. We present a case of a 56-year-old African American woman with slurred speech and altered mental status that was initially suspected to have stroke. Her chest X-ray revealed cardiomegaly and subsequent echocardiogram showed a large pericardial effusion with echocardiographic evidence of cardiac tamponade. Clinically, patient did not have pulsus paradoxus or hypotension. Further questioning revealed a history of total surgical thyroidectomy and noncompliance with thyroid replacement therapy. Pericardiocentesis was performed promptly and thyroxine replacement therapy was started. Thereafter, her mental status improved significantly. The management of pericardial effusion associated with hypothyroidism varies depending on size of effusion and hemodynamic stability of the patient. The management strategy ranges from conservative management with close monitoring and thyroxine replacement to pericardiocentesis or creation of a pericardial window.

Cardiac Tamponade: Rare presentation of Hypothyroidism

“…Reversible echocardiographic abnormalities are usually documented in a hypothyroid heart. Heart dilatation, reduced myocardial contractility, enlarged thickness of the interventricular septum and increase in the left ventricular volume had been described in the earlier studies [10] and in our study also the patients echocardiography picture had shown left ventricular hypertrophy and the dilatation of heart. This state usually mimics hypertrophic and dilated cardiomyopathies, but these abnormalities can be reversed by bringing the hypothyroid state to normal [11].…”

“…Histopathological examination of the myocardium shows interstitial edema and swelling of the muscle fibers with loss of striations, which is a hallmark of myocardial muscle. The pericardial sac usually contains fluid rich in protein and mucopolysaccharides [10]. In our study, patient also we had the pericardial fluid analysis showing rich in proteins.…”

A case of hypertensive emergency, primary hypothyroidism and large pericardial effusion with early tamponade

“…Common electrocardiographic findings of tamponade include decreased voltage with electrical alternans. Sinus bradycardia, T wave flattening has been known to be associated with hypothyroidism along with QT prolongation [2,5]. In our case the patient had a heart rate that varied between 50-70 bpm with a prolonged corrected QT interval of 495 ms in keeping with previously reported changes.…”

“…Pericardial effusion is characteristically transudative unless there is concomitant disease [2]. Echocardiographic changes of hypothyroidism include LV diastolic dysfunction with thick septa with separate E and A or inverted E/A on Doppler [2,5]. Longstanding untreated hypothyroidism can result in increased arterial stiffness leading to concentric hypertrophy as seen with our patient [6].…”

“…Onset is typically insidious without significant effects on cardiac hemodynamics given the distensibility and the ability for the pericardium to adapt. The size of the pericardial effusion is related to the duration and severity of hypothryroidism [5]. Pathophysiology of pericardial fluid accumulation is thought to be due to both impairment of the lymphatic drainage system and increase capillary permeability with underlying low oncotic pressure resulting in net influx of proteins into the pericardial space [5].…”