SAT505 Pericardial Effusion as The Primary Manifestation of Hypothyroidism

Disclosure: W. Lai: None. A. Karca: None. J. Zheng: None. Q. Shi: None. V.G. Kankani: None. A 50-year-old woman with no known past medical history, medications, or allergies. She presented with right arm pain, headache, neck swelling on the right side for 3 days. She concomitantly had loss of appetite, weight gain, drowsiness, and daytime somnolence. Denied any chest pain, nausea, or abdominal pain. Her vitals included a temperature of 96(o)F, blood pressure of 107/82mmHg, and respiratory rate of 8. She had hypoxia requiring 2L oxygen. On exam, heart sounds were distant. Significant tests included a TSH 69uIU/mL and FT4 <0.1ng/FL. Metabolic panel had a normal sodium 139mmol/L and glucose 116mg/dL. 3 a.m. cortisol level was 6.3ug/dL.EKG showed low-voltage QRS complexes. CTA chest revealed marked pericardial effusion. Echocardiogram showing septal motion abnormalities with large pericardial effusion (>20mm) suggestive of tamponade. Pericardiocentesis was performed and 800mL of serous fluid was drained. Fluid analysis showed total nucleated cell of 223/uL, lymphocyte 169.48 /uL, monocyte 51.29 /uL, RBC < 2000 /uL, protein 3.9g/dL, and glucose 81mg/dL. Pericardial effusion was negative for malignancy or infections. Patient was administered intravenous (IV) hydrocortisone, levothyroxine, and liothyronine. Her mentation and breathing gradually improved and she was discharged on oral medications. Large pericardial effusion due to hypothyroidism is rare ranging from 1-5%.[1,2] It is caused by increased permeability of pericardial capillaries with effusion of protein and glycosaminoglycan rich fluid.[3] Cardiac tamponade is an exceedingly rare presentation for hypothyroidism. Pericardial effusion secondary to hypothyroidism is treated with intravenous thyroxine. This case was complicated by concerns for myxedema crisis so glucocorticoid were given to treat possible adrenal insufficiency as the random cortisol was <18ug/dL. IV liothyronine was added to the therapy of this patient’s myxedema to provide biologic active thyroid hormone for faster onset though there is no consensus on optimal hormone treatment. [4] Pericardiocentesis is performed if tamponade is present such as this case.This case highlights variability in hypothyroidism presentation. Massive pericardial effusion complicated by cardiac tamponade in hypothyroidism is rare but exceedingly rare as primary symptom of presentation. 1. Sagrista-Sauleda J, Merce J, Permanyer-Maralda G, et al. Clinical clues to the causes of large pericardial effusions. Am J Med 2000; 109:95.2. Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusion. Medicine (Baltimore) 2003; 82:385.3. Badiu C MD, PhD. WILLIAMS TEXTBOOK OF ENDOCRINOLOGY. Acta Endocrinol (Buchar). 2019 Jul-Sep;15(3):416. doi: 10.4183/aeb.2019.416. PMCID: PMC6992389.4. Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. doi: 10.1177/0885066607301361. PMID: 17712058. Presentation Date: Saturday, June 17, 2023