“All that Glitters like Gold is Not Good.” Pericardial Effusion with Cardiac Tamponade in Hypothyroidism

CASE 1

A 55-year-old female hypertensive patient presented with complaints of shortness of breath of 2 days duration. She had drug-induced Stevens–Johnson Syndrome. Her thyroid-stimulating hormone (TSH) was 13.46 (0.4–6.1) and low triiodothyronine (T3). Other laboratory parameters were in normal range. Transthoracic echocardiography showed large pericardial effusion with tamponade, mild TR mild PAH, Trivial MR, normal LV Systolic function, and mild thickened AV with mild AR [Figure 1]. She was admitted and pericardiocentesis was done. Pericardial fluid was having golden sheen like color and analysis showed exudate. She was managed with thyroxine supplementation (50 mcg OD). The patient was stable after a few days of treatment.

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Figure 1:

2D ECHO showing pericardial tamponade in a patient with hypothyroidism.

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CASE 2

A 21-year-old female patient was diagnosed to have acute tubular interstitial nephritis and pericardial effusion, for which she was on regular medication. She had a past history of epilepsy since childhood and hypothyroidism but on irregular medication. There was sudden increase in breathlessness. On laboratory investigation, thyroid function test revealed high TSH >26 (0.4–6.1) and low T3. Transthoracic echocardiography revealed large pericardial effusion with tamponade. Pericardial tapping was done which showed golden hue color exudative effusion. The patient was stable after a few days of treatment. Levothyroxine 100 mcg once daily and is on regular follow-up with nephrologist.

CASE 3

A 62-year-old female diabetic and hypertensive patient presented with complaints of shortness of breath of 10 days duration, grade IV. SOB was slow in onset and gradually progressive. It was associated with sweating. There was sudden onset of chest heaviness, palpitation, and orthopnea/PND. On examination, her pulse was 127/min, regular, and normal in volume. Her blood pressure was 90/70 mm of Hg, respiratory rate was 40/min, and she was afebrile. She had pallor and bilateral pedal edema. On evaluation, she had high TSH and low T3 and large pericardial effusion with tamponade, left side massive pleural effusion. She was admitted to the ward and pericardiocentesis and thoracocentesis were done. She was managed with diuretics and thyroxine supplementation.

CASE 4

A 41-year-old female presented to our institution with complaints of insidious onset of shortness of breath of 10 days duration. However, there was no history of cough, pain, palpitation, swelling of legs, and syncope. Except for abnormal thyroid profile (TSH) >48 (0.4–6.1) and low T3, her laboratory investigations were within the normal range. Radiology of chest PA view showed enlarged cardiac silhouette suggestive of pericardial effusion. Transthoracic echocardiography revealed large pericardial effusion with tamponade, fair LV systolic dysfunction, trivial MR, mild TR, and Grade 1 diastolic dysfunction. Pericardiocentesis was done and is on regular follow-up.

CASE 5

A 35-year-old female presented with insidious onset of shortness of breath class II since 6 months. On evaluation, pericardial effusion was diagnosed. Laboratory investigative profile was suggestive of hypothyroidism. As patient denied admission, she was managed with oral Thyroxine supplements. On follow-up, effusion decreased and symptoms relieved.

CASE 6

A 40-year-old male referred to us with breathlessness and enlarged cardiac silhouette in chest X-ray. On evaluation, it was turned out to be large pericardial effusion with tamponade. Emergency tapping of effusion relieved the symptoms. Evaluation of blood and pericardial fluid is suggestive of hypothyroidism. The patient was discharged on oral thyroxine.

The various demographic features of the patients with pericardial fluid analysis are mentioned in [Table 1].

Pathophysiology of hypothyroidism and pericardial effusion

Incidence of pericardial effusion is around 3–6%^[3-5] in the current literature. It is more common in females. Our series also showed female preponderance with 5:1 ratio. Khaleeli and Nemon (1982) found an incidence between 30% and 78% in different series. In their study group, five out of six patients presented pericardial effusion.^[6] The salient feature of pericardial fluid in hypothyroidism is its “gold paint appearance” as first described by Alexander in 1919.^[7] This is due to the presence of cholesterol crystals due to altered lipid metabolism and churring effect of heart. The elasticity of the pericardium and the slow rate of accumulation of fluid are the two factors which makes cardiac tamponade a very rare complication of hypothyroidism.

Hypothyroidism causes pericardial effusion through increased permeability of the epicardial vessels and decreased lymphatic drainage of albumin, resulting in accumulation of fluid in the pericardial space.^[1,8] The pathophysiology of pericardial effusion is depicted in [Figure 2]. Autoimmunity does not play a major role in the pathophysiology. The classic Beck’s triad in tamponade is less seen in hypothyroid patient, instead they present with bradycardia, diastolic hypertension, and normal heart rate. When thyroid levels get corrected and normalized, pericardial effusion typically gets resolved. Aljadir, in a study performed in Iraq, reported nine out of 22 patients had pericardial and pleural effusions, besides ascites.^[9,10] In the present study, two out of six patients had both pericardial and pleural effusion. The salient features of hypothyroidism and pericradial effussion were mentioned in Table 3.

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Figure 2:

Pathophysiology of pericardial effusion.

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Management

The characteristic feature of effusion in hypothyroidism is its insidious onset due to slow collection of fluid. Hence, most of the patients do not have hemodynamic compromise. Hence, conservative management with oral or intravenous levothyroxine is sufficient in many of the cases.^[11-14] However, if there is significant collection with tamponade and hemodynamic compromise in a symptomatic patient pericardiocentesis should not be delayed.^[15] There are many case studies which showed successful management of pericardial effusion in both the ways depending on the situation. Baldwin et al.^[15] reported a series of three cases with large pericardial effusions in hypothyroidism which was managed conservatively with intravenous levothyroxine. Wang et al.^[16] reported 22.2% of patients underwent pericardiocentesis in his series of 36 patients. Kaur et al.^[17] described four cases of tamponade in hypothyroidism managed with emergency pericardiocentesis. Tudoran and Tudoran^[18] conducted study on 192 cases, 156 among them were hypothyroid and found to have effusions which were treated with no surgical intervention. Hardisty et al.^[13] conducted study on 39 hypothyroid patients, 12 among them were found to have effusions and were on conservative treatment which showed decline in effusion later.

In five out of six of our patients, pericardiocentesis was done, and then, the patients were given the hormone supplements to maintain thyroid levels. One case was managed with levothyroxine alone. The outcome of all the patients turned out to be good and they were stable and on regular follow-up. [Table 4] summarizes various case series and case reports of hypothyroidism and pericardial effusion.