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Cardiac Tamponade Physiology Caused by Large Pleural Effusion as a Manifestation of Myxedema Coma FREE TO VIEW

Monia Werlang, MD; Jose Valery, MD; Jose Diaz-Gomez, MD
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Mayo Clinic, Jacksonville, FL

Chest. 2015;148(4_MeetingAbstracts):256A. doi:10.1378/chest.2280207
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SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Myxedema coma is an uncommon but severe complication of hypothyroidism, presenting most commonly with hypothermia and altered mental status. The most described hemodynamic signs of myxedema coma are diastolic hypertension initially and hypotension afterwards. Common cardiovascular changes include cardiomegaly, bradycardia, decreased ventricular contractility and low voltage ECG. Pericardial effusion is more prevalent in more severe and longstanding disease.

CASE PRESENTATION: A fifty-three-year-old female is brought to the hospital after being found down by family member. Her past medical history was pertinent for Congestive Heart Failure, Chronic Obstructive Lung Disease and thyroid cancer status post total thyroidectomy on chronic levothyroxine replacement. Upon admission patient was hypothermic, hypotensive and acidotic. She had a similar presentation two years prior to this hospitalization when she was diagnosed with myxedema coma due to noncompliance with her levothyroxine regimen. Her family members reported patient continued to be noncompliant with her medications up to this date. Her comatose stated required orotracheal intubation, and she was admitted to the intensive care unit. Chest x-ray and limited transthoracic echocardiogram (TTE) showed large pericardial effusion, mostly posteriorly, and large left-sided pleural effusion. (Image1) The patient was started on continuous infusion of vasopressors and, due to cardiac tamponade physiology, an urgent transesophageal echocardiogram (TEE) was planned to better plan pericardiocentesis. Therapeutic left-sided thoracentesis was performed in order to optimize TEE windows. Surprisingly patient’s hemodynamic status improved dramatically immediately after thoracentesis and pericardiocentesis was deemed no longer necessary. Repeat imaging with chest x-ray and TTE showed nearly complete resolution of effusions. (Image2)

DISCUSSION: The presence of pericardial effusion in hypothyroidism seems to be related to both severity and duration of disease, being rare in the early mild state and as prevalent as 80% when myxedema coma is present. Despite the high frequency of pericardial effusions in severe hypothyroidism, moderate to large effusions are uncommon and associated tamponade physiology is noticeably rare.

CONCLUSIONS: Large pleural effusions can be associated with clinical and echocardiographic signs of tamponade and its evacuation with complete recovery of patient’s hemodynamic status. This suggests that, in a patient with tamponade physiology who has both a large pleural effusion and pericardial effusion, a pleurocentesis is probably the safest initial procedure and might result in complete recovery, as it did in our patient.

Reference #1: Chou, S.L., et al., A rare case of massive pericardial effusion secondary to hypothyroidism. The Journal of emergency medicine, 2005. 28(3): p. 293-6.

Reference #2: Arvan, S., Pericardial tamponade in a patient with treated myxedema. Archives of internal medicine, 1983. 143(10): p. 1983-4.

DISCLOSURE: The following authors have nothing to disclose: Monia Werlang, Jose Valery, Jose Diaz-Gomez

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