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Cardiac Tamponade Due to Primary
Hypothyroidism: A Rare Presentation
Hind Tahri*, Imane Tlohi, Leila Azzouzi and Rachida Habbal
Ibn Rochd University Hospital, Casablanca, Morocco
Submission: March 18, 2020; Published: March 30, 2020
*Corresponding author: Hind Tahri, Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco
How to cite this article:Hind T, Imane T, Leila A, Rachida H. Cardiac Tamponade Due to Primary Hypothyroidism: A Rare Presentation. J Cardiol & Cardiovasc
Ther. 2020; 16(1): 555930. DOI: 10.19080/JOCCT.2020.16.555930
The occurrence of pericardial effusion during a hypothyroid state is frequent. This clinical evolution justifies the realization of an echocardiographic exam at diagnosis and during follow-up in the management of patient with hypothyroid disease. The pejorative clinical signs of pericardial effusion are relatively rare; the evolution into a pericardial tamponade is not frequently reported. This retrospective report covers the clinical evolution of 3 cases of pericardial tamponade commonly demonstrating a primary hypothyroidy. The echocardiogram allowed for immediate diagnosis of the tamponade; supported by the clinical aspect and the diagnosis of hypothyroidy confirmed biologically. The treatment approach was based on pericardiocentesis of the pericardial effusion associated with progressive hormonotherapy resulting in a favorable clinical outcome and the elimination of the pericardial effusion.
Moderate to large pericardial effusion secondary to hypothyroidy is well described in the literature. Most of the reported cases highlight the rarity of cardiac tamponade in the setting of hypothyroidy, which is generally associated with recurrent viral infections contributing to the progression towards tamponade . The etiology of pericardial effusions and early diagnosis are critical in determining the clinical evolution and prognosis of these cases while potentially avoiding often costly and unnecessary exams . During our report, we discuss a series of three patients with pericardial tamponade associated to a hypothyroidy.
During 2019, three cases of tamponade were admitted to the Cardiology department at the University Hospital Center Ibn Rochd of Casablanca, of which the initial characteristics are presented in Table 1. The three cases were of female sex with a median age of 45 years. Two of the three cases presented flu-like symptoms a week prior to the hospitalization associated with the tamponade. The primary clinical signs were shortness of breath at rest and chest pain. All cases presented in a hypotensive state (without any signs of peripheric hypoperfusion) and symptoms of
right heart failure. The thyroid gland was unpalpable in the three cases.
Electrocardiogram (ECG) showed normal heart rate with low voltage pattern, electrical alternans were found in one patient (case 1). Thoracic radiography demonstrated cardiomegaly in the three cases as depicted in Figure 1.
The transthoracic echocardiogram was realized in all
cases demonstrating clinically relevant pejorative signs and
representing indications to emergency intervention; in particular,
the presence of pericardial effusion of great abundance with
compressive signs (Figure 2).
A pulse wave Doppler showed significant respiratory variations
in mitral and tricuspid inflow velocities during inspiration and
expiration in the three cases. All patient underwent an emergency
pericardiocentesis. The pericardial fluid was yellow and was sent
for cytological and biochemical investigation. The diagnosis of
hypothyroidy were based on the biological laboratory findings;
elevated TSH levels and low levels of free T3 and T4. Other than
the hormonal dosing of the thyroid, the biological findings were
negative and accompanied by complementary gynecological
examination, abdominopelvic echography, mammography,
tuberculosis panel, and panel for systemic diseases. The median
duration of hospitalization was 8 days. All patients were treated
with thyroxine 100 μg daily which was later increased gradually
to 200 μg daily with a positive clinical evolution. The 6-month
follow-up exam was free of any signs with an echocardiogram
negative for the presence of a recurrent pericardial effusion and a
normalization of the TSH levels.
Hypothyroidy can provoke pericardial effusions of various
cavities including the pericardium, peritoneum, pleura, middle
ear, uvea, joints, and scrotum . These effusions are exudative in
nature with a primary mechanism linked to the extravasation of
the hygroscopic mucopolysaccharide in the cavities with increased
capillary permeability, decreased lymphatic drainage, and greater
retention of salt and water . The fluid retention is generally
slow. The pericardium has the ability to chronically distend;
inhibiting any major hemodynamic changes even in massive
pericardial effusions . Effusions in hypothyroid patients are
generally accompanied by elevated levels of cholesterol; with
reported cases of cholesterol pericarditis causing tamponade
. Although pericardial effusions are frequent in hypothyroid
state, cardiac tamponade is primarily an occurrence in cases with
long-term disease or in patients with previous and confirmed
Most cases of cardiac tamponade are identified in older
patients of female sex. There are reports of cases of massive
pericardial effusions linked to hypothyroidism state in children
. It is important to note the presence of patients with clinically
relevant pericardial effusions in hypothyroid patients without
any clinical signs and symptoms of hypothyroid disease such as:
weight gain, fatigue, and edema. This was also the case in two of
the three patients (case 1 and 3 in this report where hypothyroid
signs and symptoms were completely absent). Consequently,
hypothyroidy is to be evaluated in all patients with an unexplained
The classical signs of cardiac tamponade (triad of Beck) are
arterial hypotension, elevation of central venous pressure, and
muffled heart sounds; of note these signs were not always present
in the patients described in this report. Although the paradoxical
pulse is habitual, it is not always evident. The pericardial friction is
usual with effusion of low to medium abundance . The ECG can
carry clinical information in this setting by identifying a microvoltage
with an electric alternance which can be caused by either
pericardial effusion or myxedema. The diagnosis of pericardial
effusion is generally suspected by a radiographic examination
of the thorax and confirmed by cardiac echocardiogram which
remains the gold standard with a high specificity and sensitivity.
The echocardiographic signs of tamponade were present in the
three patients in this report, associated with a tele-diastolic
collapse of the right ventricle, compression of the right atrium,
and a deviation of the interventricular septum in the left ventricle
at inspiration .
With adequate medical treatment of hypothyroidism with
thyroid hormones and steroids, the vast majority of pericardial
effusions resolve slowly but completely; surgery is rarely required.
Pericardiocentesis or surgical intervention are often not necessary
unless the presence of pericardiac tamponade is confirmed .
The occurrence of cardiac tamponade in hypothyroidism is
very rare due to the slow accumulation of fluid and pericardial
distensibility. When tamponade occurs, it can be caused by
provoking factors such as concomitant viral pericarditis.
Hypothyroidism should be ruled out in all patients with
unexplained pericardial effusion. This should be considered
in the general population and not exclusively in patients with
clinically manifest hypothyroidism or in the elderly. Finally, once
the diagnosis is established, treatment with thyroid hormones
generally leads to the resolution of the pericardial effusion for
2-12 months without sequelae.