Pericardial effusion is relatively common in patients with uncontrolled hypothyroidism, but rarely, it progresses to cardiac tamponade. We describe a case of myxedema coma presenting with cardiac tamponade.
A 63-year-old African American morbidly obese lady with history of hypothyroidism presented with worsening dyspnea and unresponsiveness. Family reported that she is non-compliant with levothyroxine. Vitals recorded BP 85/69, HR 56, RR 31, SaO2 96% on RA, temperature 35.4 C. Her exam was remarkable for generalized edema, unresponsive, wheezes and crackles bilateral lungs. She was emergently intubated for airway protection, and was treated for possible septic shock. Her labs were significant for VBG- pH 7.12, PvCO2 75, PvO2 34, HCO3 27; TSH-88.40, BGM 109, Hb 10.7, WBC 5.9 and normal cortisol level. CT head didn’t show any acute abnormality. EKG showed normal sinus rhythm with non-specific changes. Bedside cardiac ultrasound showed pericardial effusion, confirmed to be cardiac tamponade by stat echocardiogram. She was treated with stress dose steroids, IV levothyroxine and underwent emergent pericardiocentesis; with symptomatic improvement.
Pericardial effusion can be present in ~3-6% patients with hypothyroidism. There are few cases reports of patients presenting with cardiac tamponade, and rarely this could be the presenting feature in patients with myxedema coma. The presentation might not be typical for tamponade, and unlike other causes of tamponade, absence of tachycardia should raise the index of suspicion for hypothyroidism. Hypothyroid patients presenting with hypotension should be urgently evaluated by cardiac echo to rule out pericardial effusion and possible tamponade, a truly life saving procedure.