hannahpotmd

Authors: Hannah C. Urbanozo¹, Marcelyn A. Fusilero², Marc Gregory Y. Yu³, Cherrie Mae C. Sison¹

1 Section of Endocrinology, Diabetes and Metabolism, University of the Philippines-Philippine General Hospital, Department of Medicine, Manila, Philippines

2 Section of Cardiology, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines

3 Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines

Cardiovascular alterations in the thyrotoxic patient are attributed to hypermetabolism and the need to dissipate the excess heat produced, which results to increased circulatory demands. While sinus tachycardia, atrial fibrillation and congestive heart failure with long-standing atrial fibrillation are well-recognized cardiovascular manifestations of thyrotoxicosis, the occurrence of pericardial effusion due to thyrotoxicosis is rarely reported.

We report the case of a 32-year-old Filipino woman in the 23^rd week of her fourth pregnancy, with a seven-year history of a gradually enlarging anterior neck mass associated with palpitations, exophthalmos, heat intolerance and easy fatigability. She was treated as a case of thyroid storm on initial presentation at the emergency room, with a baseline FT4 of 40.2 pmol/L and TSH of 0.1 uIU/ml and subsequently discharged. She developed exertional dyspnea, 3-pillow orthopnea and bipedal edema without associated chest pain or fever, days after discharge. Echocardiogram on readmission revealed massive pericardial effusion in tamponade. Her FT4 upon at this time was within normal limits. Immediate pericardiostomy was done. Pericardial fluid was negative for mycobacterium tuberculosis or any bacterial isolates. Serum ANA was likewise negative. After initial pericardiostomy and treatment with anti-thyroid medications and prednisone, pericardial effusion resolved.

Table 1: Pericardial Fluid Studies

Qualitative Examinations	Result
Color	Dark red
Transparency	Slightly hazy
Red Blood Cells	283,000 x 10⁶/L
White Blood Cells	578 x 10⁶/L
Polymorphonuclear Cells	82%
Lymphocytes	17%
Distorted Cells	0.01%

Glucose	4.95 mmol/L
Total Protein	59.01

Gram Stain	PMN 0-1/OIF Gram positive cocci in pairs 0-1/OIF
Bacterial Culture	No growth
AFB Smear	Negative
AFB Culture	No growth
Cytology

A repeat 2decho upon follow-up showed no residual effusion. To date, there are no published cases in the Philippines on thyrotoxic pericardial effusion.

In a thyrotoxic patient with worsening heart failure symptoms despite adequate treatment, it is prudent to consider a pericardial effusion, to facilitate timely management.

Fig. 1. Chest radiograph on 1st admission, with LV cardiomegaly

Fig. 2. Chest radiograph on 2nd admission showing water-bottle shaped cardiomegaly

References:

Kahaly G, Dillmann W. Thyroid Hormone Action in the Heart. Endocrine Reviews. 2005. 26(5):704–728.

Sampana A, Jasul G. High Grade AV Block Complicating Hyperthyroidism: A Case Report. Philippine Journal of Internal Medicine July-Septemner 2010; 48:2.

Braunwald E, Fauci AS, Kasper D, Hauser HL, Longo D, Jameson JL. Disorders of the thyroid gland. In: Braunwald E, Fauci AS, Kasper D, Hauser HL, Longo D, Jameson JL, editors. Harrison’s principles of internal medicine. 15th ed. Vol 2. New York: McGraw-Hill; 2001. p. 2069-73.

Ovadia, S, Lysy y L, Zubkov T. Pericardial effusion as an expression of thyrotoxicosis. Tex Heart Inst J 2007; 34:88-90.

Teague E, O’Brien C, Campbell N. Pericardial effusion and tamponade complicating treated Graves’ thyrotoxicosis. Ulster Med J 2009; 78 (1) 56-58.

Nakata A, Komiya R, Ieki Y, Yoshizawa H, Hirota S, Takazakura E. A patient with Graves’ disease accompanied by bloody pericardial effusion. Internal Medicine 2005; 44(10):1064-1068.)

Levy PY, Corey R, Berger P, Habib G, Bonnet JL, Levy S, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003; 82: 385-91.

Strange dream last night:

Me and my dad were both desperately trying to get back home, on foot and exhausted from an ordeal that I was no longer able to retrieve from my memory when I woke up. Stuck in a hedge maze, we encounter a guide in the form of a woman (ethereal in appearance, complete with white flowing gown and glowing skin) who leads us to the mouth of a concrete tunnel, with the following instructions: “the tunnel takes you home fast, but you can only go one at a time and you have to be certain that you can be fast enough to avoid on-coming vehicles that travel at break-neck speeds that will not be able to see you, nor you it, to see as you make quick dashes from blind corners…“

The real-world me pondered at this strange scenario when i woke up…but let me continue with the story since I remained asleep at that point of the dream…

I decided I would be fast enough and in fact, would be faster than my dad in outrunning the chance of an oncoming vehicle putting my lights out permanently. I did not even feel fear as I glanced at my rubber shoes – half expecting it to magically give me a speed boost, and braced myself at the mouth of the tunnel that seemed to go on and on, without any hint of light at its end. My first dash was a short 3-meter run…I made it, barely missing the oncoming sedan that strangely did not have its headlights on nor made a sound.

To my dream-self, the sedan was just a motion blur, but I somehow understood at that point, how real the danger was. It was then that I felt fear. It was palpable, but I was able to come to terms with it by deciding not to push through, for the reason that: my dad might not be able to reach me in time if I ran into trouble, since we were made to go through the tunnel one at a time.

I woke up with a fuzzy head and threw a furtive glance at my bedside clock – time for work.

As I prepped for another weekday, I remember how many matters I needed to deal with as chief fellow of the prestigious Section of Endocrinology of the Philippine General Hospital. I feel the weight of the responsibilities on my ill-equipped shoulders once again. To shake it off, I afforded myself a short distraction by trying to make sense of my weird dream. Then I breathed a short prayer.

And then I remembered my D-group leader’s constant reminder to my constant complaints of being burned out: “Don’t try to keep doing it all alone. Do not draw from your own strength but from God’s.”

Then the dream made sense to me. I may be fast enough to avoid problems that I see come my way, but I will never be able to avoid those that I cannot. I do not have control over everything and neither can I see every task to complete success without God. My dream-self dared not go where her father was not going…I am finding out how neither should my real-self do too.

Exodus 33: 15-16: 15Then Moses said to him, “If your Presence does not go with us, do not send us up from here.16 How will anyone know that you are pleased with me and with your people unless you go with us?What else will distinguish me and your people from all the other people on the face of the earth?” scary-tunnel