Refractory Pericardial Effusion Secondary to Central Hypothyroidism due to Empty Sella Syndrome: A Rare Case Report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Refractory pericardial effusion secondary to central hypothyroidism due to empty sella syndrome (n=1). Intervention: Levothyroxine and glucocorticoids. Primary outcome: Resolution of pericardial effusion.

Q: What does this research mean for the field?

Central hypothyroidism secondary to empty sella syndrome can present as refractory pericardial effusion, necessitating glucocorticoid replacement prior to levothyroxine administration. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Bishal Mandal; Prativa Subedi; Bishal Kumar Yadav; Bipin Pandey; Bishwa Raj Adhikari; Saurav Jha; Milan Gaihre

doi:10.1002/ccr3.73399

October 1, 2026Clinical Case ReportsOpen Access

Refractory Pericardial Effusion Secondary to Central Hypothyroidism due to Empty Sella Syndrome: A Rare Case Report

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Key result

Levothyroxine with glucocorticoid coverage resolves refractory pericardial effusion in central hypothyroidism.

n=1

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Why the study?

Refractory pericardial effusion with low free T4 and inappropriately normal TSH requires evaluation for central hypothyroidism and treatable causes like empty sella syndrome.

Key Points

To highlight central hypothyroidism secondary to empty sella syndrome as a reversible cause of refractory pericardial effusion and outline the necessary hormonal evaluation and management sequence.
Evaluated a 42-year-old postmenopausal woman presenting with a large refractory pericardial effusion and central hypothyroidism associated with primary empty sella syndrome.
Administered prednisone (0.5 mg/kg/day tapered over 1 month), colchicine (0.5 mg PO daily for 1 month), and levothyroxine (25 mcg PO daily titrated every 4 weeks targeting upper half of free T4 reference range).
Assessed the hypothalamic-pituitary-adrenal axis with a short Synacthen test 2 weeks following steroid taper and monitored cardiac status via serial echocardiograms.
The short Synacthen test performed 2 weeks post-steroid taper revealed an adequate cortisol response, enabling safe discontinuation of glucocorticoid therapy.
Thyroid hormone replacement titrated by free T4 led to complete normalization of free T4 levels without relying on thyroid-stimulating hormone levels.
Serial echocardiograms at 1, 3, and 6 months of follow-up demonstrated no recurrence of pericardial effusion, with the patient remaining entirely asymptomatic.

Study Design

Type

Case Report (n=1)

Structured PICO

P

Population

A 42-year-old postmenopausal female presenting with refractory pericardial effusion and central hypothyroidism due to primary empty sella syndrome, followed for 6 months.

I

Intervention

Levothyroxine 25 mcg daily, combined with prednisone 0.5 mg/kg/day and colchicine 0.5 mg daily, following initial pericardiocentesis and continuous drainage.

O

Outcome

Resolution of pericardial effusion and normalization of free T4 levels.

Refractory pericardial effusion combined with a low free T4 and inappropriately normal TSH should prompt evaluation for central hypothyroidism, emphasizing the necessity of glucocorticoid cover prior to thyroid hormone replacement.

Limitations

Dynamic ACTH testing was not performed at index admission
Visual-field perimetry and a formal somatotrophic-axis assessment were planned but not available at the index admission
Concurrent steroid and colchicine therapy precludes a clean attribution to thyroid hormone replacement alone
Visual-field perimetry and a formal somatotrophic-axis assessment were not available at the index admission

Implication

Case report supports glucocorticoid cover before levothyroxine in central hypothyroidism with refractory effusion; hypothesis-generating, needs prospective validation.

Abstract

Refractory pericardial effusion with a low free T4 but inappropriately normal TSH should prompt evaluation for central hypothyroidism, including pituitary MRI to identify treatable causes such as empty sella syndrome. Glucocorticoid cover must precede levothyroxine to prevent adrenal crisis in patients with possible hypopituitarism.

Discussion

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Cite This Study

Mandal et al. (2026) conducted a case report in Refractory pericardial effusion secondary to central hypothyroidism due to empty sella syndrome (n=1). Levothyroxine and glucocorticoids was evaluated on Resolution of pericardial effusion. Levothyroxine therapy preceded by glucocorticoid coverage resulted in complete resolution of refractory pericardial effusion secondary to central hypothyroidism.

synapsesocial.com/papers/6ac74632947fe0d7c56432db https://doi.org/10.1002/ccr3.73399

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Refractory Pericardial Effusion Secondary to Central Hypothyroidism due to Empty Sella Syndrome: A Rare Case Report

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Refractory Pericardial Effusion Secondary to Central Hypothyroidism due to Empty Sella Syndrome: A Rare Case Report

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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