Impending cardiac tamponade: a rare initial manifestation of
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The present case has been reported in BMJ. A 37-year-old woman with a history of psoriatic arthritis presented to the emergency department with back pain radiating to the upper abdomen for 1 week with no other associated symptoms. Physical examination revealed normal vital signs, mild enlargement of the thyroid gland, jugular venous distension and distant heart sounds.

Laboratory results revealed elevated thyroid-stimulating hormone at 134.76 U/mL, decreased free T4 at 0.27 ng/dL and T3 at 1.7 ng/dL. Testing for cyclic citrullinated peptide antibody, antinuclear antibody and rheumatoid factor was negative. ECG showed sinus rhythm at 63 beats per minute and low-voltage complexes.

Chest X-ray showed cardiomegaly. CT of the abdomen and pelvis revealed an incidental large pericardial effusion and no remarkable abdominal pathology. Echocardiography confirmed large pericardial effusion with an early tamponade physiology.

She underwent pericardiocentesis with drainage of 1400 mL of exudative fluid. Bacterial, fungal and mycobacterial cultures were negative, with no malignant cells seen. Thyroperoxidase antibodies were highly elevated (>1000 IU/mL).

Ultrasound of the thyroid gland showed a diffusely enlarged, heterogeneous thyroid consistent with Hashimoto’s thyroiditis. Treatment was started with intravenous levothyroxine 100 µg daily for 3 days followed by oral levothyroxine.

Pericardial effusion was attributed to severe hypothyroidism as all the other common aetiologies had been ruled out. Six weeks after discharge, follow-up echocardiogram showed only trivial pericardial effusion.

Learning points
• Impending cardiac tamponade is a rare initial manifestation of hypothyroidism.

• Hypothyroidism should be considered in the differential diagnosis in patients with massive pericardial effusion even when other classic signs are absent or poorly evident.

• In patients with severe hypothyroidism who manifest with pericardial effusion, classic signs of tamponade such as tachycardia and hypotension may be absent; instead, they may have normal blood pressure and heart rate.

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