Massive pericardial effusion secondary to Hashimoto's disease

Although relatively rare, hypothyroidism remains a significant cause of moderate to severe pericardial effusion. Pericardial effusion secondary to hypothyroidism does not usually cause symptoms since it tends to regress slowly and ultimately disappear several months after the patient has reverted to the euthyroid state. Thus, hypothyroidism must be ruled out in patients with an unexplained pericardial effusion, both to improve prognosis and to avoid unnecessary pericardiocentesis. Even when they have a massive pericardial effusion, patients should receive the standard treatment for hypothyroidism. We herein describe a 79-year-old woman with a massive pericardial effusion associated with hypothyroidism who showed a good response to standard levothyroxine replacement therapy after 5months.     

Pericarditis caused by cholesterol. Apropos of a clinical case

A case of a 76 year-old woman with a large pericardial effusion is described. The microscopic examination of the scintillating, yellow-greenish fluid obtained by the first pericardiocentesis, showed numerous crystals of cholesterol. In search of the underlying diseases there were found values of T3, T4 and TSH diagnostic of hypothyroidism. Considering the rapid relapse of the effusion and after a second pericardiocentesis, it was decided to open a pleuro-pericardial window. The biopsy of the pericardium showed deposits of cholesterol on electronics microscopy. She was discharged from hospital two weeks after surgery, showing an evident clinical improvement. Six months later she was feeling well, keeping a normal activity for her age. The values of T3, T4 and TSH were normal, and there were no echocardiographic signs of pericardial effusion. It is presented a rare case of cholesterol pericarditis associated to sub-clinical hypothyroidism, showing the presence of cholesterol, as crystals in the pericardial effusion and, we think for the first time in this pathology, in vesicles of pinocytosis, in the pericardial biopsy. The six months period of follow-up showed a good clinical improvement with the selected therapeutic attitude.     

Recurrent pericardial effusion with a common clinical disorder

We present a case of recurrent pericardial effusion in a patient with Down's syndrome in whom the underlying cause was not considered because of unfamiliarity with the care of people with Down's syndrome. The diagnosis hypothyroidism only became apparent by means of a routine panel of biochemical tests.     

Cardiac tamponade due to low-volume effusive constrictive pericarditis in a patient with uncontrolled type II autoimmune polyglandular syndrome

Abstract

Type II autoimmune polyglandular syndrome (APS), a relatively common endocrine disorder, includes primary adrenal insufficiency coupled with type 1 diabetes mellitus and/or autoimmune primary hypothyroidism. Autoimmune serositis, an associated disease, may present as symptomatic pericardial effusion. We present a case of a 54-year old male with APS who developed pericarditis leading to cardiac tamponade with a subacute loculated effusion. After urgent pericardiocentesis intrapericardial pressure dropped to 0, while central venous pressures remain elevated, consistent with acute effusive constrictive pericarditis. Contrast computerized tomography confirmed increased pericardial contrast enhancement. The patient recovered after prolonged inotropic support and glucocorticoid administration. He re-accumulated the effusion 16 days later, requiring repeat pericardiocentesis. Effusive–constrictive pericarditis, an uncommon pericardial syndrome, is characterized by simultaneous pericardial inflammation and tamponade. Prior cases of APS associated with cardiac tamponade despite low volumes of effusion have been reported, albeit without good demonstration of hemodynamic findings. We report a case of APS with recurrent pericardial effusion due to pericarditis and marked hypotension with comprehensive clinical and hemodynamic assessment. These patients may require aggressive support with pericardiocentesis, inotropes, and hormone replacement therapy. They should be followed closely for recurrent tamponade.     

Transient diabetes insipidus and hypopituitarism after pituitary apoplexy: a rare association with pericardial effusion and painless thyroiditis

Pituitary apoplexy in a 38-year-old male patient with acromegaly who presented with pericardial effusion, anterior pituitary dysfunction, and diabetes insipidus is described. With corticosteroid therapy, there was good initial recovery of pituitary function and regression of pericardial effusion. On withdrawal of corticosteroids, he developed painless thyroiditis, with transient thyrotoxicosis. Subsequently, the pituitary function tests remained normal for a year, but later he gradually developed hypogonadotropic hypogonadism, hypocortisolism, growth hormone deficiency, and progressive pituitary atrophy, resulting in empty sella syndrome.     

甲状腺功能减退症与心血管病

目的全面了解甲状腺功能减退症(甲减)患者心血管系统表现和心血管并发症、合并症,为诊断甲减提供参考。方法回顾性分析心血管内科收入的甲减患者心血管系统表现和心血管并发症、合并症及其构成比、内在的相互关系。结果本研究甲减患者男性少于女性(男女人数1∶3),半数以上有相关病史;可合并(并发)贫血、心房纤颤、高血压病、冠心病、心包积液、高脂血症等心血管病;可存在多种非特异性的心电图异常,可有血清肌酶升高;贫血、血脂升高、心包积液、肌酶升高可同时存在或两种以上情况并存,如一个患者同时无这四种(或后三种)情况可排除甲减。结论甲减与心血管病有密切、广泛的联系,血脂升高、心包积液、肌酶升高、贫血至少存在一项异常。     

Prolonged persistence of a large pericardial effusion and hemodynamic evidence of cardiac tamponade during treatment of myxedema

We describe clinical, echocardiographic, and catheterization findings that were present initially and during therapy in a myxedematous patient with a large pericardial effusion and tamponade. Treatment with thyroxine resulted in a marked improvement of most of the clinical features of hypothyroidism and some improvement in cardiac function. However, the pericardial effusion as well as clinical and laboratory evidence of tamponade persisted for 2 months after full replacement doses of T4 had been achieved. The tamponade was finally relieved by fenestration of the parietal pericardium. These findings are consistent with evidence of an abnormality of pericardial drainage that persists for months after other thyroid hormone dependent functions are normalized by thyroxine replacement. Therefore prompt surgical drainage rather than dependence on medical therapy alone is indicated in myxedematous patients who have cardiac tamponade.     

PERICARDIAL EFFUSION IN HYPOTHYROIDISM

Thirty-nine patients with untreated hypothyroidism have been examined using echocardiography for the presence of a pericardial effusion. Effusions were present in twelve patients who tended to be more severely hypothyroid. Plasma creatine phosphokinase and lactate dehydrogenase levels were higher in the presence of an effusion. Nine were reinvestigated during thyroxine replacement therapy and the effusions did not disappear until thyroid function tests had returned to normal. There were no specific electrocardiographic changes associated with the presence of an effusion which could be associated with a normal cardiac silhouette on a standard P.A. chest X-ray.     

Transient elevation of serum tumor markers in a patient with hypothyroidism

We report a case of a 66-year-old woman admitted to our hospital for examination and treatment of uterine and rectal prolapse, pleural and pericardial effusion, and ascites. On further examination, she was diagnosed with hypothyroidism. Test results showed markedly elevated concentrations of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 125 (CA 125). We consequently performed multiple imaging studies, none of which detected a malignancy. Hormonal replacement therapy with levothyroxine was started, and the pleural and pericardial effusion and ascites gradually abated. Concentrations of serum CEA and CA125 also decreased gradually after therapy with levothyroxine. These findings indicate that in patients with hypothyroidism, elevated CEA and CA125 levels do not necessarily indicate malignancy. Conversely, in any patient with elevated serum CEA and/or CA125, hypothyroidism should be considered in the differential diagnosis.     

Pericardial tamponade in a patient with treated myxedema

Pericardial tamponade developed in a patient with hypothyroidism and a pericardial effusion after she had been successfully treated with levothyroxine sodium. Refractory pericardial effusion is an unusual complication of treated myxedema. A possible mechanism for its occurrence is presented.     

Vitiligo, hypothyroidism and cardiomyopathy

Vitiligo in association with autoimmune endocrine disorders, especially with hypothyroidism, is not uncommon. Some amount of pericardial effusion is usually present in long-standing/untreated hypothyroidism. Here we describe the case of young male with, long-standing progressive vitiligo, presenting with congestive cardiac failure due to dilated cardiomyopathy and primary hypothyroidism. Cardiac dysfunction progressively improved with thyroid hormone replacement over a period of 2 years.     

Cardiac tamponade preceding skin involvement in progressive systemic sclerosis

The frequency of pericardial involvement in Systemic Sclerosis (SSc) is high on autoptic or echocardiographic studies, but the clinical recognition of pericarditis with or without effusion is rare. We describe a case of a 71-year-old female with no previous history of heart disease, who presented with a large pericardial effusion and tamponade that required pericardial drain. She had suffered from Raynaud's phenomenon since 25 years. Six weeks after hospital discharge she complained of skin hardening on left leg. Pericardial tamponade is a very rare manifestation of SSc and occurs both early or late in the course of the disease, but in our case it preceded the recognition of scleroderma. We have only identified two other cases of pericardial effusion preceding cutaneous involvement in scleroderma.     

Recurrent pericardial effusion and pericardial tamponade in a patient with limited systemic sclerosis

We describe a patient with limited systemic sclerosis who presented with a large pericardial effusion with tamponade on echocardiogram, requiring pericardiocentesis to drain 1.2 l of fluid. She had a rapid re-accumulation of pericardial fluid and subsequently required a pericardial window. Although small pericardial effusions are common in patients with systemic sclerosis it is rare to have hemodynamic compromise. Previously reported large pericardial effusions have been seen in patients with pulmonary hypertension and renal failure however these were absent in our patient.     

A case of primary cardiac lymphoma located in the pericardial effusion

Primary cardiac lymphoma is a rare disorder with a poor prognosis. We present here a case of 77-year-old woman who was diagnosed as having cardiac lymphoma antemortem according to a cytologic examination of the pericardial effusion. Determination of the levels of serum-soluble interleukin-2 receptor and serum deoxythymidine kinase was useful for the diagnosis. Echocardiography, computed tomography, magnetic resonance imaging, and gallium scan revealed neither lymphadenopathy nor tumor in the heart, so she was diagnosed as having malignant lymphoma that probably originated from the pericardium. Systemic chemotherapy with CHOP (cyclophosphamide, farmorubicin, oncovin, and prednisolone) resulted in a complete resolution of the pericardial effusion. She has been in remission 48 months after discontinuation of the chemotherapy.     

Carcinoid heart disease from ovarian primary presenting with acute pericarditis and biventricular failure

A case is described of a 54 year old woman who had acute pericarditis with large exudative effusion accompanied by severe right and left ventricular failure. The patient was finally diagnosed with carcinoid heart disease from an ovarian carcinoid teratoma. She was treated with octreotide--a somatostatin analogue--followed by radical surgical resection of the neoplasm. At one year follow up only mild carcinoid tricuspid regurgitation remained. Only 16 cases of carcinoid heart disease from an ovarian primary have been described in literature. Moreover clinically manifest acute, nonmetastatic pericarditis and left heart failure are not considered as possible presentations of carcinoid heart disease, whatever the origin. In a recent series a small pericardial effusion was considered an infrequent and unexpected echocardiographic finding in carcinoid heart patients. One case of "carcinoid pericarditis" has previously been described as a consequence of pericardial metastasis. Left sided heart involvement is usually caused by bronchial carcinoids or patency of foramen ovale; both were excluded in the case presented.     

Primary cardiac angiosarcoma. Extended resection of the right atrial wall. Case report

We report the case of a 51-year-old patient who presented with tiredness and leg swelling, with recurrent pericardial effusion; a right atrial tumor, suggestive of sarcoma, was diagnosed, which responded poorly to chemotherapy. In the absence of metastases, surgery for excision of the tumor was undertaken. Two months after surgery she had a new recurrence of pericardial effusion and chemotherapy was reinitiated. She is currently well and asymptomatic, with no signs of recurrence ten months after surgery and nearly 24 months after the initial diagnosis.     

The syndrome of cardiac tamponade with "small" pericardial effusion

Cardiac tamponade is usually a consequence of increased pericardial pressure with accumulation of pericardial effusion. Pericardial effusion may be caused by acute pericarditis, tumor, uremia, hypothyroidism, trauma, cardiac surgery, or other inflammatory/noninflammatory conditions. In this article we describe four scenarios illustrated by case reports where a small or apparently small pericardial effusion may produce cardiac tamponade. The first scenario illustrates how a small pericardial effusion can cause clinically significant cardiac tamponade when it accumulates rapidly. The second scenario exhibits how an apparently small pericardial effusion on transthoracic echocardiogram (TTE) turned out to be a small amount of unclotted blood and an echogenic hematoma. The third scenario details how an apparently small pericardial effusion on TTE was actually a large loculated effusion in an unusual location seen only by transesophageal echocardiogram (TEE). The fourth scenario demonstrates how the combination of a large pleural effusion and a small pericardial effusion can result in cardiac tamponade. The role of echocardiography in the diagnosis and management of these scenarios is discussed here. Although many clinicians depend on the amount of pericardial effusion to suspect cardiac tamponade, it is important to suspect cardiac tamponade when patients have hemodynamic compromise regardless of the amount of pericardial effusion.     

原发性甲状腺功能减退性心包积液与甲状腺功能、心肌酶、胆固醇的关系

目的探讨原发性甲状腺功能减退性心包积液与甲状腺功能、心肌酶、总胆固醇的关系。方法回顾性分析90例原发性甲状腺功能减退症合并心包积液患者,进行甲状腺功能、心肌酶、总胆固醇的调查,并按有无心包积液分为2组进行比较。结果 (1)两组患者在年龄、性别构成、病程、病因上差异无统计学意义。(2)甲状腺功能减退伴心包积液组患者TT3、TT4、FT3、FT4均较无心包积液组低[(0.66±0.48)nmol/L比(1.20±0.57)nmol/L,(14.64±24.46)nmol/L比(62.22±50.67)nmol/L,(2.11±0.74)pmol/L比(3.66±2.02)pmol/L,(3.12±4.49)pmol/L比(6.37±4.78)pmol/L],而TSH较无心包积液组高[(68.85±32.05)mU/L比(46.47±39.44)mU/L,均为P<0.05]。(3)心包积液组心肌酶谱、胆固醇均较无心包积液组高(P<0.05)。(4)偏相关分析提示心包积液与TT3、TT4、FT3、FT4、TSH相关(r=-0.400,-0.467,-0.368,-0.340,0.284;均为P<0.05)。结论原发性甲状腺功能减退性心包积液与甲状腺功能严重程度有关,与年龄、病程、病因无关,同时多伴有胆固醇及心肌酶谱升高。     

Massive pericardial effusion in a hypothyroid child.

A child with Down's syndrome and long standing severe hypothyroidism had a massive pericardial effusion without cardiac tamponade. The effusion completely resolved with medical treatment without pericardiocentesis.     

AIDS associated with severe cor pulmonale and large pericardial effusion with cardiac tamponade

Cardiac involvement in patients with advanced HIV/AIDS is common, including pericardial effusion and pulmonary hypertension. Although there is an increased incidence of pericardial effusion in patients with AIDS, most are small and asymptomatic. The presence of a pericardial effusion and/or pulmonary hypertension is associated with shortened survival. We present a case of a 43-year-old man with AIDS and advanced cardiovascular involvement who developed severe cor pulmonale and a large pericardial effusion with cardiac tamponade.