Pericardial decompression syndrome in a patient with hypothyroidism presenting as massive pericardial effusion: a case report and review of related literature

Abstract

The authors present a case of a 44-year-old female with unrecognised hypothyroidism consulting for heart failure symptoms. Echocardiogram revealed massive pericardial effusion with tamponade physiology, attributed to primary hypothyroidism from a previous thyroidectomy. Levothyroxine was started at a dose of 0.7 ug/kg/day followed by subxiphoid pericardiostomy. 9 h postpericardiostomy however, hypotension developed and despite hydration and inotropic support, patient succumbed to cardiogenic shock on the 14th hospital day.

Figure 1

Chest radiograph taken on anteroposterior-view show an apparently enlarged heart (computed cardiothoracic ratio of 1:2), with a water-bottle configuration and bilateral pleural effusion on the left more than the right, with no infiltrates nor congestive changes.

Figure 2

Initial transthoracic echocardiogram revealed massive pericardial effusion with an echo-free space measuring 43 mm posteriorly and 19 mm anteriorly on short axis M-mode (asterisk over black area), and tamponade physiology based on a swinging heart, diastolic collapse of the right ventricle (white arrow), IVC plethora, a 36% relative inspiratory augmentation in tricuspid (right-side) flow and a 28% relative decrease in inspiratory flow across the mitral valve. The left ventricle (yellow arrow) was normal in size with good wall motion, and an ejection fraction of 73%. The left atrium, right atrium and right ventricle were all in normal size.

Figure 3

Chest radiograph postpericardostomy show resolution of pleural effusion, with cardiomegaly cardiothoracic ratio 1:2.

Figure 4

Repeat transthoracic echocardiogram shows resolution of the previously noted pericardial effusion but now with segmental wall motion abnormalities and a significant drop in ejection fraction to 46%.