Clinical Case Report

Massive pericardial effusion without cardiac tamponade due to subclinical hypothyroidism (Hashimoto's disease)


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Panteleimon E Papakonstantinou1
MD, Internal Medicine Resident *

Nikolaos Gourniezakis2 MD, Consultant Internal Medicine

Christos Skiadas3 MD, Consultant Radiology

Alexandros Patrianakos4 MD, PhD, Consultant Cardiology

Achilleas Gikas5 MD, PhD, Professor of Internal Medicine, Head of the Internal Medicine Department


1, 2, 5 Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece

3 Department of Radiology, University Hospital of Heraklion, Heraklion, Crete, Greece

4 Department of Cardiology, University Hospital of Heraklion, Heraklion, Crete, Greece

ACCEPTED: 21 September 2017

early abstract:

Context: Hypothyroidism is a significant cause of pericardial effusion. However, large pericardial effusions due to hypothyroidism are extremely rare. The hormone replacement therapy is the cornerstone of treatment in hypothyroidism and a regular follow up of the patients after the initiation of the therapy is indicated. Herein, we present a 70-year-old woman with a massive pericardial effusion due to Hashimoto's disease.
Issues: A 70-year-old female, from a rural village in Crete island, was admitted to our hospital due to urinary tract infection. She was under replacement therapy with levothyroxine 100mcg once a day due to Hashimoto's disease. Two years ago, the patient had an episode of pericarditis due to hypothyroidism and she had undergone a computerised tomography (CT)-guided pericardiocentesis. The patient did not have a regular follow up and did not take the hormone replacement therapy properly. On admission, the patient's chest X-ray showed a possible pericardial effusion, which was an incidental finding. The patient referred for echocardiography, which revealed a massive pericardial effusion. Beck's triad was absent. Thyroid hormones were : TSH: 30.25 (normal limits: 0.25-3.43) μUl/ml; Free Thyroxin 4 : 0.81(normal limits: 0.7-1.94 ng/dl) which were consistent with subclinical hypothyroidism. According to the ESC position statement on triage strategy for cardiac tamponade, the patient had a score of 5 and despite the absence of cardiac
tamponade, a pericardiocentesis was performed after 48 hours. The patient was treated with levothyroxine 125 mcg orally OD.
Lessons learned: This was a rare case of an elderly woman patient, rural citizen, with chronic massive pericardial effusion due to subclinical hypothyroidism without cardiac tamponade. Hypothyroidism should be in our differential diagnosis of pericardial effusion, especially in a case of unexplained pericardial fluid. Initiation of hormonal replacement therapy should be personalized in elderly patients. TSH levels >10mU/l usually require therapy with levothyroxine in order to prevent the adverse events. Rural citizens usually
do not have a regular follow up after the initiation of the hormone replacement therapy. Pericardial effusions due to hypothyroidism grow slowly and subclinical hypothyroidism rarely gives signs and symptoms and can be underdiagnosed. The ESC position statement on triage strategy for pericardial diseases is a valuable clinical tool to estimate the necessity for pericardial drainage in such cases.