LETTER TO THE EDITOR |
https://doi.org/10.5005/jp-journals-11006-0026 |
A Rare Case of Hypothyroidism Presenting as Massive Pleuropericardial Effusion
1-4Department of Pulmonary Medicine, Army Institute of Cardio-Thoracic Sciences (AICTS), Armed Forces Medical College, Pune, Maharashtra, India
Corresponding Author: Robin Choudhary, Department of Pulmonary Medicine, Army Institute of Cardio-Thoracic Sciences (AICTS), Armed Forces Medical College, Pune, Maharashtra, India, Phone: +91 9673300582, e-mail: robinch19@gmail.com
Received on: 15 November 2022; Accepted on: 16 November 2022; Published on: 31 December 2022
ABSTRACT
The cause of pleuropericardial effusion can be varied and includes many differential diagnoses. One of the very rare causes of pleuropericardial effusion can be hypothyroidism. The clinical findings of hypothyroidism are generally subtly leading to delay in diagnosis. We present a case of a middle-aged patient who presented at our tertiary care center with massive pleuropericardial effusion due to hypothyroidism which was managed conservatively. Hypothyroidism can present as pleuropericardial effusion and the treating physician should keep that differential while evaluating and treating such cases.
How to cite this article: Marwah V, Choudhary R, Tripathi S, et al. A Rare Case of Hypothyroidism Presenting as Massive Pleuropericardial Effusion. Indian J Crit Care Case Rep 2022;1(3):87-89.
Source of support: Nil
Conflict of interest: None
Keywords: Eltroxin, Hypothyroidism, Massive pleuropericardial effusion.
Sir,
Pleuropericardial effusion is not an unusual finding but their differential diagnosis stances a clinical impasse. Pleuropericardial effusion as a presenting feature raises the possibility of infectious, inflammatory, iatrogenic (drug-induced), neoplastic, and connective tissue disorders. Apart from the above concurrent effusions are caused due to end-stage renal disease, hypothyroidism, acute respiratory distress syndrome, and acute pancreatitis.1,2 Isolated case reports and small series of patients with a single etiologic diagnosis abound; systematic studies of combined thoracic effusions have unfortunately not been published.3 We report a case of hypothyroidism in a middle-aged female presenting as massive pleuropericardial effusion.
A 40-year-old female with a known case of juvenile myoclonic epilepsy on oral sodium valproate, oxcarbazepine, and clobazam for the last 25 years. She presented with a history of nonproductive cough and progressive breathlessness of modified Medical Research Council (mMrc) grade II progressing to mMRC grade 3–4 months duration. Her breathlessness used to increase on lying down. She also had a history of nonspecific left-sided chest pain, which was retrosternal, dull aching, and intermittent without any radiation or any aggravating or relieving factors. On examination, she had pallor, pedal edema, and raised jugular venous pressure. Her saturation was 86% on room air and 94% with a face mask at 6 L/minute. On evaluation, she had low hemoglobin, raised C-reactive protein (CRP) (80 mg/L), and thyroid-stimulating hormone of 38.8, as well as decreased triiodothyronine (T3) and thyroxine (T4) (Table 1). Her chest radiograph showed cardiomegaly (Fig.1), and her electrocardiogram showed low voltage complexes. She underwent a high-resolution contrast-enhanced computed tomography of the chest, which showed a large pericardial effusion with a maximum thickness of 50 mm overlying the left ventricle region (Fig. 2). The parietal pericardium was seen abutting the anterior and left lateral chest wall, and there is a resultant passive collapse of the left lower lobe lung. There was also mild bilateral pleural effusion. Her two-dimensional echocardiography showed normal ejection fraction and normal valves with large circumferential pericardial effusion with early right ventricular collapse suggestive of impending cardiac tamponade. In view of impending cardiac tamponade, diagnostic cum therapeutic pericardiocentesis was done, eight French pigtail catheter was inserted in the pericardial space, and 1100 mL of pericardial fluid was drained. Pericardial fluid analysis showed exudative effusion with predominantly neutrophils and adenosine deaminase (ADA) 21 IU/L (Table 2). However, the patient started having intermittent spikes of fever, which was high grade and subsidized with a nonsteroidal anti-inflammatory drug. The workup was done to rule out bacterial, mycobacterial, viral, and fungal infections, but it was negative. Her CRP level was persistently high, but her serum procalcitonin was below <0.5 ng/mL. Both pericardial and pleural effusion staining showed no gram stain susceptible organisms or acid-fast stained organisms and was also negative for the fungal stains and cultures. A nucleic acid amplification test done in both the effusion fluids did now detect any mycobacterium tuberculosis (MTB) complex. Interferon γ release assay was also negative for MTB. As CRP was high, a workup for connective tissue disorder was done in the form of antinuclear antibodies (ANA) anticyclic citrullinated peptides and extracted ANA panels, which were all negative. She was diagnosed with a case of massive pleuropericardial effusion secondary to hypothyroidism and was managed with oral T4. The patient showed significant clinic-radiological improvement and also in her thyroid profile. The patient has been under follow-up for the last 6 months and is presently asymptomatic.
Day 1 | Day 10 | Day 15 | |
---|---|---|---|
T3 (ng/dL) | 6.8 | 29 | 42 |
T4 (ug/dL) | 4.37 | 6.21 | 8.84 |
TSH (mIU/L) | 38.8 | 5.0 | 3.54 |
Pleural fluid analysis | ||
---|---|---|
Albumin | 1.5 gm/dL | (3.4–5.0) |
Total protein | 3.9 gm/dL | (6.4–8.2) |
Sugar | 127 mg/dL | (74–100) |
Lactate dehydrogenase (LDH) | 107 U/L | 100–190 |
ADA | 4 | Upto 34 U/L |
Total white blood cells (WBC) | 700/cu mm | |
Total red blood cells (RBC) | Nil | |
Predominant cells | Lymphocytes |
Pericardial fluid analysis | ||
---|---|---|
Albumin | 2.2 gm/dL | (3.4–5.0) |
Total protein | 5.8 gm/dL | (6.4–8.2) |
LDH | 449 U/L | 100–190 |
ADA | 21 U/L | Upto 34 U/L |
Total WBC | 2800/cu mm | |
Total RBCs | 100/cu mm | |
Predominant cells | Neutrophil |
Fig. 1: Chest radiograph showing cardiomegaly and pleural effusion (left)
Figs 2A and B: High-resolution contrast enhanced computed tomogram of the chest showing massive pericardial effusion. The parietal pericardium is seen abutting the anterior and left lateral chest wall, and there is a resultant passive collapse of the left lower lobe lung. There is also mild bilateral pleural effusion
DISCUSSION
Hypothyroidism is one of the most common endocrine disorders seen in routine practice. Clinical symptoms of hypothyroidism are generally diverse and nonspecific. However, despite its simple and common diagnosis, it is difficult to speculate subsequent complications of hypothyroidism.3 Hypothyroidism has been documented to be the cause of effusions in the pleural, pericardial, and other serous body cavities.4-7 Tissue edema is among the commonest clinical finding in cases of hypothyroidism. It has rarely been known to cause serous cavity effusions. Isolated findings like pericardial effusion, pleural effusion, or ascites are not unusual, whereas the combination of multiple body cavity effusions is extremely rare.2 Pericardial effusions can occur, and the mechanism includes an increase in the volume of distribution of albumin and a decrease in lymphatic clearance function. Occasionally the pericardial effusions are quite large, causing the appearance of cardiomegaly on the chest radiograph.8 Up to 25% of patients with hypothyroidism may develop pleural effusion.9 Cases of pleural effusion have been described in patients with subclinical hypothyroidism [elevated thyroid-stimulating hormone (TSH), normal FT4] and with elevated vascular endothelial growth factor, the latter having been related to excess extravascular fluid.10 Hypothyroid pleural effusion usually resolves following hormone replacement therapy.11 Hypothyroidism and its presenting features are generally ignored and undertreated. Weight gain, cold intolerance, fatigue, and constipation in a long-standing case are generally overlooked by the patient as well as the treating physician. Treating physicians should keep a differential of hypothyroidism in a case of pleuropericardial effusion cases, especially in a clinical setting and in the background of hypothyroidism.
ORCID
Vikas Marwah https://orcid.org/0000-0002-7033-6090
Robin Choudhary https://orcid.org/0000-0002-9641-6849
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