A 42‐year‐old woman with a history of Graves' disease status post thyroidectomy and type II diabetes presented with a 3‐day history of dyspnea on exertion. The patient has also had right‐sided chest pain that was sharp in nature. The chest pain was aggravated by lying down and relieved by sitting up. The patient had taken levothyroxine daily after thyroidectomy, but she had stopped taking it 3 years ago. She reported that she was tired of taking pills. On examination, pulse was 103 beats per minutes. There were engorged neck veins, systolic murmur at the left parasternal border, mild pitting edema on bilateral lower extremities. Other examination findings were normal. Laboratory results revealed hemoglobin level of 7.2 G/dL, TSH of 115.73 uIU/mL (normal range, 0.35–5.5 uIU/mL), free T4 of 0.3 ng/dL (normal range, 0.56–1.64 ng/dL), CK of 518 U/L (normal range, 30–233 U/L), CK‐MB of 7 NGng/mL (normal range, 0–5 ng/mL). ANA was negative. EKG showed sinus tachycardia with poor R‐wave progression. CT scan of the chest revealed a large circumferential pericardial effusion measuring up to 1.8 cm wide. Echocardiogram showed a large pericardial effusion with tamponade findings, ejection fraction of 40%–45%, and severe mitral regurgitation. The patient underwent a pericardial window operation, and 400 mL of fluid was drained. Pericardial fluid cytology was negative for malignancy. There was no growth on pericardial fluid cultures. Cardiac tamponade in this case resulted from noncompliance with levothyroxine for the treatment of iatrogenic hypothyroidism. Levothyroxine was administered. Her symptoms improved after the procedure. Education regarding the importance of taking levothyroxine daily and an appointment with an endocrinologist were provided to the patient.
Pericardial effusion in patients with hypothyroidism is a common finding; however, cardiac tamponade is a rare clinical manifestation. Echocardiography is primary diagnostic modality. Treatment of cardiac tamponade includes pericardiocentesis or pericardial window creation; however thyroid replacement is a cure therapy of hypothyroidism‐induced pericardial effusion. Cardiac tamponade in this case was caused by the patient's noncompliance with levothyroxine, so patient education and follow‐up are vital in management of patients with hypothyroidism.
Cardiac tamponade could be an initial presentation of hypothyroidism. Therefore clinicians should consider hypothyroidism in the differential diagnosis of pericardial effusion or tamponade.
To cite this abstract:Anuwatworn A, Joshi R. Cardiac Tamponade: A Rare Initial Presentation of Iatrogenic Hypothyroidism. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 309. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/cardiac-tamponade-a-rare-initial-presentation-of-iatrogenic-hypothyroidism/. Accessed April 5, 2020.