Massive pericardial effusion without cardiac tamponade due to subclinical hypothyroidism (Hashimoto's disease)

[helvella]

Please note - this is claimed as a case of subclinical hypothyroidism. More specifically, under-medicating though read the paper for full details.

Although it has general interest, I particularly thought of Marz - and that it was good to see a contribution from doctors of Crete, not just the patients.

Clinical Case Report

Massive pericardial effusion without cardiac tamponade due to subclinical hypothyroidism (Hashimoto's disease)

AUTHORS

Panteleimon E Papakonstantinou1 MD, Internal Medicine Resident *

Nikolaos Gourniezakis2 MD, Consultant Internal Medicine

Christos Skiadas3 MD, Consultant Radiology

Alexandros Patrianakos4 MD, PhD, Consultant Cardiology

Achilleas Gikas5 MD, PhD, Professor of Internal Medicine, Head of the Internal Medicine Department

CORRESPONDENCE

*Dr Panteleimon E Papakonstantinou

AFFILIATIONS

1, 2, 5 Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece

3 Department of Radiology, University Hospital of Heraklion, Heraklion, Crete, Greece

4 Department of Cardiology, University Hospital of Heraklion, Heraklion, Crete, Greece

PUBLISHED

20 May 2018 Volume 18 Issue 2

HISTORY

RECEIVED: 18 February 2017

REVISED: 1 July 2017

ACCEPTED: 21 September 2017

CITATION

Papakonstantinou PE, Gourniezakis N, Skiadas C, Patrianakos A, Gikas A. Massive pericardial effusion without cardiac tamponade due to subclinical hypothyroidism (Hashimoto's disease). Rural and Remote Health 2018; 18: 4384. doi.org/10.22605/RRH4384

AUTHOR CONTRIBUTIONS

© Panteleimon E Papakonstantinou, Nikolaos Gourniezakis, Christos Skiadas, Alexandros Patrianakos, Achilleas Gikas 2018 A licence to publish this material has been given to James Cook University, jcu.edu.au

abstract:

Context: Hypothyroidism is a significant cause of pericardial effusion. However, large pericardial effusions due to hypothyroidism are extremely rare. Hormone replacement therapy is the cornerstone of treatment for hypothyroidism and regular follow-up of patients after initiation of the therapy is indicated. Herein, the case of a 70-year-old woman with a massive pericardial effusion due to Hashimoto’s disease is presented.

Issues: A 70-year-old female from a rural village on the island of Crete, Greece, was admitted to our hospital due to a urinary tract infection. She was under hormone replacement therapy with levothyroxine 100 µg once a day for Hashimoto’s disease. Two years previously, the patient had had an episode of pericarditis due to hypothyroidism and had undergone a computed tomography-guided pericardiocentesis. The patient did not have regular follow-up and did not take the hormone replacement therapy properly. On admission, the patient’s chest X-ray incidentally showed a possible pericardial effusion. The patient was referred for echocardiography, which revealed a massive pericardial effusion. Beck's triad was absent. Thyroid hormones were consistent with subclinical hypothyroidism: thyroid-stimulating hormone (TSH) 30.25 mIU/mL (normal limits: 0.25–3.43); free thyroxin 4 0.81 ng/dL (normal limits: 0.7–1.94). The patient had a score of 5 on the scale outlined by the European Society of Cardiology (ESC) position statement on triage strategy for cardiac tamponade and, despite the absence of cardiac tamponade, a pericardiocentesis was performed after 48 hours. The patient was treated with 125 µg levothyroxine orally once daily.

Lessons learned: This was a rare case of an elderly female patient from a rural village with chronic massive pericardial effusion due to subclinical hypothyroidism without cardiac tamponade. Hypothyroidism should be included in the differential diagnosis of pericardial effusion, especially in a case of unexplained pericardial fluid. Initiation of hormone replacement therapy should be personalised in elderly patients. TSH levels >10 mU/L usually require therapy with levothyroxine in order to prevent adverse events. Rural patients usually do not have regular follow-up after the initiation of hormone replacement therapy. Pericardial effusions due to hypothyroidism grow slowly and subclinical hypothyroidism rarely shows signs and symptoms and can be underdiagnosed. The ESC position statement on triage strategy for pericardial diseases is a valuable clinical tool to estimate the necessity for pericardial drainage in such cases.

keywords:

cardiac tamponade, Hashimoto’s disease, pericardial effusion, subclinical hypothyroidism.

The full article is freely available here:

rrh.org.au/journal/article/...

[SmallBlueThing]

A similar case, with an unhappy outcome: academic.oup.com/ajcp/artic...

[humanbean]

I find it frightening that a TSH of 30 can be called "subclinical" because of the stupid way that the disease is defined. I really wish that the division between "subclinical" and "overt" hypothyroidism could be ditched and that there was just one condition called "hypothyroidism" that people got treated for.

[Hidden in reply to humanbean]

The maximum TSH range given on my results was only 0.27-4.2 mU/L (mine was 5.94, but T4 was still within range).

Do different authorities use different ranges or what???

[humanbean in reply to Hidden]

"Subclinical" hypothyroidism is defined by doctors as TSH being over the range and Free T4 being in the range. There is no upper limit on the TSH level in definitions of subclinical hypothyroidism, so someone could have a TSH of 30 or 50 or 100 and a Free T4 that is low in range, and doctors are technically still allowed to ignore it because it's "subclinical".

Since they (doctors) rarely test Free T3 it could be zero for all they care. And yet patients have discovered that it is the level of Free T3 that matters in terms of feeling well or ill.

The ranges for just about every test can differ from lab to lab, however the top of the TSH range is one that is reasonably consistent - it usually varies (in the UK) from about 4.5 - 5.5 as far as I'm aware.

Free T4 ranges are far less consistent, and can range from 7 - 17 to 12 - 24 in the UK. In some places they use different units of measurement for Free T4 and so the ranges look entirely different to those in the UK.

[Hidden in reply to humanbean]

"There is no upper limit on the TSH level in definitions of subclinical hypothyroidism, so someone could have a TSH of 30 or 50 or 100 and a Free T4 that is low in range, and doctors are technically still allowed to ignore it because it's "subclinical"."

That is dreadful!!!! I'm not much above the TSH upper limit but already getting lots of symptoms. Hopefully the results of a recent blood test will show below limit T4 - they might get a move on then.

Hope I can actually SEE and discuss things with a doctor next time, instead of a telephone consultation. That's OK for something simple, but this common and theoretically "Simple" thyroid problem has turned out to be anything but!

[humanbean in reply to Hidden]

I have to say it would be unusual to have an extremely high TSH with Free T4 still being in range.

But odd results of all sorts do happen.

Some people have blood tests that show a TSH of 100 or more and yet they have no symptoms at all, which I find amazing and eye-watering.

My own TSH never got higher than just under 6, and yet my Free T4 and Free T3 were very low in range.

The people with a very high TSH and no symptoms get loads of sympathy from their doctors, but people like me who are struggling hugely (or I was) are dismissed with a wave of the hand for years.

[Hidden in reply to humanbean]

Mine isn't that high - yet - but already have some less than nice symptoms. And ALT in the liver is too high, as well as triglycerides (cholesterol)

[greygoose in reply to humanbean]

Totally agree with that!

[Furface in reply to humanbean]

And as for the fact that they say sub clinical hypothyroidism does not usually show any symptoms! They have stopped listening to patients full stop. I had 98 symptoms at the last appointment. None taken into account yet I could barely walk, had so much pain, chest pain, irregular heartbeat and brain wouldn't work. They put it all down to depression and then gave up on me.

[humanbean in reply to Furface]

That sounds very like my experience. I gave up on doctors and started paying for my own testing and treating myself. I made mistakes along the way (either over-treating or under-treating), but I haven't killed myself yet, and despite the occasional mistakes I have never regretted treating myself.

[Furface in reply to humanbean]

At least we stand a chance of improving that way. I also self medicate and self test. Why would anyone depend on a dr (s) who clearly hasn't a clue and blags it, keeping their patients ill. They had twenty years of my life, they are not having anymore.

[Hidden]

Thank you so much for this, will help give me courage to push for treatment if and when it becomes necessary. Especially as I'm nearly 70 and still "Subclinical"

[Bluedragon]

I would think she was still under medicated on 125 and feeling very poorly with a TSH of 30!

It would have been interesting to see her FT3 and anti body levels. Typical they weren’t included.

Thanks Helvella, an interesting article.

[ShootingStars in reply to Bluedragon]

The article says she wasn't taking her medication properly, so that's why she had TSH of 30. Yikes!

Some people completely can't understand about how to take thyroid medication correctly, not matter what you tell them. Someone taking T4 and a large dose of T3 couldn't figure out how for the life of them how they could be taking such high levels and still have such intense fatigue and other symptoms. After several inquiries, it was finally revealed that they have been taking T4....in the middle of the day not on an empty stomach! T3 by itself first thing a.m. They are still not understanding how they could possibly have symptoms with these high doses and think it doesn't matter how they take thyroid medication, despite being informed about how thyroid medication is supposed to be taken. They think it doesn't matter.

Some people just don't want to listen or follow instructions. Perhaps that is how it was for the 70 year old woman with the massive pericardial effusion. Maybe she wanted to do it "her way".

[DeeD123 in reply to ShootingStars]

I was never told by anyone in the medical profession how to take mine. For years I took them with my morning coffee ( black ) maybe this lady was the same

[Hidden in reply to ShootingStars]

That is likely true with some people, but when you are reasonably intelligent and sensible (when brain fog allows) and are not given the information you need and not listened to when you KNOW you need medication, that is really frustrating

[DeeD123 in reply to Hidden]

I can also say hand on heart that I was fine during that time with no symptoms and a full and active life. Internet wasn’t available to the masses back then so I had to rely on the medical profession for guidance

[TrishaL]

Could this be what is causing the fluttering feelings in my heart? It feels as though my heart isn't working smoothly. Like lots of mini palpitations followed by the occasional big thump.

[humanbean in reply to TrishaL]

Obviously nobody here can diagnose heart problems for you. But one of the most common problems associated with the heart in people with thyroid problems is low minerals and vitamins and low Free T3.

Low levels of magnesium, vitamin B12, folate, iron, ferritin, potassium and vitamin D can have effects on all sorts of muscles - and the heart is just a muscle. There are no doubt a few others that can affect the heart that I don't know about.

Low Free T3 is something people aren't aware of because it rarely gets tested. And yet it affects every cell in the human body, including the heart - too much or too little can cause lots of problems.

[TrishaL in reply to humanbean]

Thank you - my Free T3 is 4.4 so that may be the issue

[helvella Administrator Thyroid UK in reply to TrishaL]

As humanbean says, none of us can diagnose your heart issues.

I have not the least idea of what it feels like to suffer from pericardial effusion.

We can have our views about how the emdical establishment handles thyroid issues, but they do have a lot of experience and equipment for investigating heart issues. If you have any doubt as to what you are feeling, do get yourself to a doctor.

[Clarrisa in reply to TrishaL]

Have you had a EKG (electrocardiogram)? If the EKG is performed while you are experiencing your mini palpitations it may capture exactly what they are. That information can aid treatment.

[TrishaL in reply to Clarrisa]

Hi Clarissa,

Yes I had an EKG but the doctor said my heart was fine. Of course it only runs for less than a minute and the palpitations are low level, more like a constant fluttering, so that didn’t surprise me. As Shootingstars says, it feels as though it is linked to the low Free T3.

Thank you !

[helvella Administrator Thyroid UK in reply to TrishaL]

A Holter monitor (one you carry with you for many hours) is often used to collect evidence. Have you asked for, or been offered, that?

[Clarrisa in reply to TrishaL]

I had to have what the Cardiologist called a "Tracing" to capture my irregular beats. The tracing runs for a longer period of time, several minutes or so. It didn't look like as many leads as a 12 lead EKG were captured. It seemed more like a telemetry reading graphing one or fewer leads. The Cardiologist felt my irregularity was related to stress.

[ShootingStars in reply to TrishaL]

Hi TrishaL. If you have too low FT3 or FT4, or too high FT3 or FT4, you can have an irregular heart rhythm. The low end of the range and too high in the range is where the most symptoms are found in general.

[Bluedragon in reply to TrishaL]

I had palpitations- especially on an evening- and found they disappeared on being diagnosed B12 deficient and having injections.

I also got them when I was raising my NDT dose initially too high and then had a coffee. I’ve also had them from anxiety or when feeling stressed. Note when you get them, are they triggered? Your low FT3 could also be a causative factor.

As others have said, especially Human Bean, vitamin and minerals could be your problem. Please get tested before supplementing. It is impossible to get proper readings once you do. Ask your doctor for B12, folate, ferritin and Vitamin D tests. Then tell us the results. Otherwise Medichecks for example include them on a thyroid check ultravit, currently £99.

medichecks.com/thyroid-func...

Jo

[Hidden in reply to Bluedragon]

I read somewhere, or was told, that if B12 is too high it can also cause problems - I think it can interfere in some way with the folate levels or absorption. Sorry to be so vague - perhaps someone here has more information?

[helvella Administrator Thyroid UK in reply to Hidden]

Very high B12 when not supplementing is an indication of issues which could be serious.

The folk over on Pernicious Anaemia Society are often best informed about the relationship between folate and B12.

[Hidden in reply to helvella]

Thanks, will check it out