SESSION TITLE: Critical Care Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Myxedema Crisis (MC), a rare life-threatening complication of hypothyroidism, is associated with cardiac manifestations. Presented is a case of cardiac tamponade combined with cardiomyopathy.
CASE PRESENTATION: A 57-year-old woman presented to the emergency department with mid-epigastric pain denying other gastrointestinal symptoms. No chronic medical problems or use of daily medications was noted. Physical examination revealed a temperature of 94 degrees Fahrenheit and blood pressure 90/70 mmHg on 5 mcg/kg/min of Dobutamine and 0.04 mcg/kg/hr of Norepinephrine. She was pale, somnolent with slow mentation. She had dry mucous membranes, distant heart sounds, clear lungs but a benign abdomen and decreased lower extremity pulses. Notable labs were cardiac troponin 24.1 ng/ml, TSH 68.2 uIU/mL, and free thyroxine 0.3 ng/dL. Arterial blood gas showed pH 7.19, pCO2 42.9 and pO2 65 on BiPAP. Chest radiograph showed significant cardiomegaly (figure A). Computed tomography showed a large pericardial effusion (figure B). Echocardiogram demonstrated global cardiomyopathy (EF 25-30%) and right ventricle compression by a large circumferential pericardial effusion with collapse < 50% of the cardiac cycle (Figures C & D). Features were consistent with cardiac tamponade prompting emergent pericardial fluid drainage. Fluid was negative for infection, malignancy and auto immune antibodies. Given the clinical findings and elevated TSH, she was diagnosed with MC. Prior to discharge from a prolonged hospital stay; her cardiomyopathy showed marked improvement with thyroid replacement.
DISCUSSION: Hypothyroidism is present in 5.8% of the population, but MC is seen in only 0.1% of this sub group1. MC is a clinical diagnosis based on presentation and supported by labs. Cardiovascular complications include sinus bradycardia, low voltage complexes, conduction abnormalities and nonspecific ST-T changes1. Pericardial effusions and are uncommon, but more frequent in severe hormone deficiency states such as MC, yet rarely progresses to tamponade impairing ventricular function. A review of previous attempts to describe this effusion indicates that it is likely a result of increased capillary permeability and electrolyte disturbances2,3. When present, immediate cardiac decompression is required along with thyroid replacement3.
CONCLUSIONS: Cardiac tamponade and cardiomyopathy are rare MC complications requiring immediate lifesaving surgical and medical therapy. Recovery from cardiomyopathy is more gradual with long term hormone replacement.
Reference #1: Mathew V, Misgar RA, Ghosh S, Mukhopadhyay P, Roychowdhury P, Pandit K, et al. "Myxedema coma: a new look into an old crisis" J Thyroid Res. 2011; 2011:493462.
Reference #2: Kabadi UM, Kumar SP. “Pericardial effusion in primary hypothyroidism” American Heart Journal Dec 1990;120(6 Pt 1):1393-1395.
Reference #3: Martin L, Spathis G, “case of Myxoedema with a huge pericardial effusion and cardiac tamponade”, British Medical journal, July 1965; 2(5453): 83-85.
DISCLOSURE: The following authors have nothing to disclose: Abdulla Majid-Moosa, Jeffery Schussler, Adam Mora
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