By: Alexander Hilbmann MD
HPI:
52 year old female with pmhx of hypothyroidism who presents to Emergency Department with bilateral leg swelling and SOB with exertion. Reports swelling began one week ago and has progressively worsened. Denies any other symptoms. Patient has not seen a cardiologist/had an echo performed before. Reports she has not taken her prescribed levothyroxine for two years now.
Physical Exam:
Vitals BP 128/82 HR 80 BPM Temp 92.8F Oral Resp 29 SpO2 99%
Abnormalities on physical Exam:
Periorbital Swelling of bilateral eyes
Rales present in bilateral lower lungs
Distension of abdomen
Bilateral lower extremities with non pitting edema
12 Lead ECG:
Interpretation: Sinus bradycardia, low voltage ECG
Bedside subxiphoid cardiac ultrasound:
Interpretation: Circumferential pericardia effusion, RV collapse consistent with pericardial tamponade physiology
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Case continued:
- Patient found to be hypoglycemic at 50 mg/dL, D10 administered
- Patient found to be hyponatremic at 125, likely in setting of fluid overload
- Cardiology consulted for cardiac tamponade, pericardiocentesis performed with 1.4 L drained.
- Ascites drained via paracentesis, other diagnoses ruled out with hypothyroidism most likely cause.
- Patient restarted on levothyroxine and began liothyronine (T3)in hospital
- Patient discharged home in stable condition after 10 days in hospital with levothyroxine, has not returned to hospital since
Pearls:
- Consider hypothyroidism if patient has pmhx or classical physical exam findings: bradycardia, hypothermia, hypotension, lethargy, constipation, hair loss/thinning, facial swelling, coarse skin, pretibial myxedema(thickened, nonpitting edema), menstrual changes, decreased reflexes.
- Hypothyroidism increases permeability in the blood vessels of the body and decreases drainage of lymphatic system, causing an accumulation of fluid outside of blood vessels and can present as pretibial myxedema, pericardial effusion, or pleural effusion.
- Precipitating factors of hypothyroidism include medication nonadherence, infection, cold exposure, stroke, autoimmune disorders, thyroid radiation/surgery, and medications (amiodarone, lithium).
- Management of hypothyroidism includes supportive, hydrocortisone(prevents adrenal crisis), levothyroxine (T4) and +/- Liothyronine (T3) supplementation.
References:
Chahine J, Ala CK, Gentry JL, et al Pericardial diseases in patients with hypothyroidism Heart 2019;105:1027-1033.
Patil N, Rehman A, Jialal I. Hypothyroidism. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519536/
