Massive Pericardial Effusion-Rare and Only Presentation of Hypothyrodism- Myxedematous Heart

Abstract

Cardiovascular symptoms are often predominant features in patients with hyperthyroidism. But cardiovascular findings in hypothyroidism are more subtle. Hypothyroidism mainly presents as lethargy, cold intolerance, constipation, proximal muscle weakness, weight gain, decreased appetite, coarse dry skin, hair loss and nonpitting edema. Cardiovascular findings in hypothyroidism are mild degree of bradycardia, diastolic hypertension and narrow pulse pressure. Mild degree of pericardial effusion is seen in up to 30% of overtly hypothyroid patients. There are several case reports on myxedema ascites, but only few case reports of hypothyroidism presenting as massive pericardial effusion. We report a case of 54-year-old female presenting with breathlessness and found to have massive pericardial effusion without tamponade. After extensive workup, she was found to have primary hypothyroidism. In contrast, she had no other symptoms and clinical signs suggestive of hypothyroidism. She was improved after treatment with levothyroxine. Keywords: Hyperthyroidism; Pericardial effusion; Levothyroxine Case PresentationA 54-year-old female (weight 49 kg; BMI 18 kg/m 2 ) presented to our department with class 2 breathlessness for last 6 months which had progressed to class 3 for last 1 month. She had no previous history of diabetes, hypertension and coronary artery disease. Vitals showed, blood pressure of 110/70 mmHg, heart rate of 112/min, respiratory rate of 20/min, SpO 2 of 94% and she was afebrile. Her general physical examination was normal, JVP was not raised and there was no pedal edema. Cardiovascular examination showed only muffled heart sounds, respiratory system was normal and on neurological examination her tendon reflexes were not delayed.On investigations, electrocardiogram showed low voltage complexes, chest X-ray showed water bottle heart (Figure 1) and on echocardiography there was massive pericardial effusion without evidence of diastolic collapse of right atrium and right ventricle. Thickness of pericardial effusion in apical 4 chamber view was 33 mm (Figure 2), in parasternal long axis view was 31.8 mm (Figure 3) and in parasternal short axis view was 21.5 mm (Figure 4). Hb was 13 gm%, ESR 21 mm 1 st hr, urea 31 mg/dl, creatinine 0.9 mg/dl, serum proteins (total 6.5 gm/dl, albumin 3.5 gm/dl), SGOT 31 IU, SGPT 35 IU, ANA was negative and urine examination was also normal.

Case series of unusual cases of hypothyroidism-induced pericardial effusion

“…[ 1 2 ] According to the literature, pericardial effusion occurs in only 3 percent of mild forms of the disease and is uncommon as a first presentation. [ 3 4 ] It is challenging to diagnose it early due to the discordance between the fluid’s volume and clinical symptoms presented by the patient. [ 5 ] The effusion volume is directly proportional to the duration and severity of the hypothyroid state.…”

Pericardial effusion in hypothyroidism: A case report

“…The incidence varies to be as high as 80% in severe, long-standing, and congenital hypothyroidism, and only 3% in early stages and mild form of the disease [ 6 ]. The frequency of pericardial effusion in well-established myxedema justifies the need to assess pericardial effusion; however, its occurrence in mild cases and as first presentations cannot be overlooked [ 4 , 7 ].…”

A Case Report of Hypothyroidism and Pericardial Effusion

“…The pericardial and myocardial diseases group from the European Cardiology Society has proposed a new step-by-step scoring system for those patients who require pericardiocentesis[11] [15] [22] [23] [24] [28][34]. The pericardial effusion It can present a clinical challenge mainly due to the discordance between the total volume of the effusion and the clinical symptoms shown by the patient.…”