Elderly Woman With Massive Pericardial Effusion, Cardiac Tamponade, and Hypothyroidism

To the Editor: A 74-year-old woman, was brought for geriatric consultation after having a fall while walking in the street. She reported feeling dizzy; she had no cranial trauma or loss of conscience. On past history, family reported having high blood pressure diagnosed 3 months before, treated with enalapril and spironolactone. She was reported to be independent for basic activities of daily living but had difficulty managing finances 3 months before consultation and had stopped preparing meals 1 month before. She reported fatigue, hyperoxia, and moderate exertional dyspnea. Physical examination revealed an elderly woman with moderate alopecia, no neck vein distention, a pericardial rub, a systolic murmur most audible on the mitral area, and generalized nonpitting edema. On cognitive and affective screening there were no abnormalities. Routine laboratory data showed hemoglobin of 11 g/dL; mean corpuscular volume of 91 fL; white blood cell count of 3,900/μL, platelets of 288,000/μL, glucose of 92 mg/dL and creatinine of 0.6 mg/dL. Because of cardiac abnormalities detected on clinical grounds, a transthoracic echocardiogram was performed. It showed pericardial effusion with hemodynamic compromise because of diastolic collapse of the right chambers, approximate volume of 300 mL, and concentric parietal hypertrophy, diastolic dysfunction, and ejection fraction of 72%. Thyroid function tests were ordered and found a thyroid-stimulating hormone (TSH) of 36.9 mIU/mL. Hospitalization for pericardiocentesis was suggested, but the patient and family refused treatment. Levothyroxine 12.5 μg/d was initiated. One month later, the patient presented for consultation again, so a new echocardiogram was performed that indicated a small pericardial effusion of 20 mL. Thyroid dysfunction prevalence increases with age.1 There is an aging-associated decrease in thyroxine production rate, compensated for by a decrease in plasma clearance rate and a mild decrease in triiodothyronine, although TSH levels remain stable.2 Incipient hypothyroidism occurs in 2.7% to 3.5% of elderly men and 7.1% to 17.6% of elderly women. Autoimmune hypothyroidism (Hashimoto thyroiditis) is the most common cause of thyroid failure in older adults.3 Deficiency and excess of thyroid hormones are examples of atypical disease presentation in older adults, symptoms of thyroid diseases may be absent or erroneously attributed to normal aging or coexisting diseases.4 Echocardiography is the primary diagnostic method for pericardial effusion, which is recognized as an echo-free space between the parietal and visceral pericardium surrounding the heart. Cardiac tamponade is seen when the increasing pericardial pressure exceeds the intracardiac pressure, so echocardiogram shows right atrium wall inversion; this is usually a first sign of compression, followed by diastolic compression of the right ventricular outflow tract.5 Hypothyroidism is associated with increased capillary permeability and impaired lymphatic drainage with subsequent leakage of protein into the interstitial space, resulting in pericardial effusion. Chronic pericardial effusion is well tolerated, because the pericardial sac stretches through a phenomenon called “stress relaxation,” which is the tendency of a tissue to increase in length after it has been stretched to a given tension, so the pericardial space may accommodate 2 L of fluid gradually without increasing intrapericardial pressure until it reaches a critical point.6 Treatment of pericardial effusion with cardiac tamponade is pericardiocentesis or creation of a pericardial window,7 although hypothyroidism-related pericardial effusion is reported to resolve with levothyroxine treatment. In a report series of 56 medical patients with cardiac tamponade, myxedema was the etiology in 4% of cases.8 Massive pericardial effusion in patients with hypothyroidism has been reported in the literature;9,10 to our knowledge, this is the first case of pericardial effusion with cardiac tamponade associated with hypothyroidism that resolved without drainage. Pericardial effusion with cardiac tamponade is a rare initial presentation of hypothyroidism in older adults, so hypothyroidism should be included on the initial assessment of pericardial effusion or tamponade in older adults. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors were involved in the concept and design of the manuscript. Sponsor's Role: No sponsorship was involved in the development of the manuscript.