particularities of pericardial effusion in patients with hypothyroidism

Journal of Experimental Medical & Surgical Research
Cercetãri Experimentale & Medico-Chirurgicale
Year XVIII Nr.4/2011 Pag. 176 - 179
C. Tudoran 1 ,
M. Tudoran 1 ,
R. Avram 1 ,
M. Balaº 2 ,
M. Vlad 2 ,
I. Zosin 2
PARTICULARITIES OF PERICARDIAL EFFUSION IN
PATIENTS WITH HYPOTHYROIDISM
Received for publication:
15.08.2011
Revised: 13.09.2011
1 - Clinic of Cardiology, University of Medicine and Pharmacy, Timiºoara
2 - Clinic of Endocrinology, University of Medicine and Pharmacy, Timiºoara
INTRODUCTION
Pericardial effusion is a common finding in patients
with hypothyroidism witch represents the most common
clinical disorder of thyroid function. Worldwide, iodine
deficiency is the usual cause of hypothyroidism, but in
iodine-sufficient areas, the most common cause is
autoimmune thyroiditis. The apparition of symptoms is
very gradual, with durations of several months, occasionally
even one or two years.(1)
176
JOURNAL of
Experimental
Medical Surgical
R E S E A R C H
Summary:
In hypothyroid patients pericardial effusion occurs with an incidence described to be
compressed between 3% and 80 %, in correlation with the severity and duration of the
thyroid disorder. This liquid is usually in small or moderate amount and is rich in
mucopolysaccaride and cholesterol. We studied the incidence and evolution of pericardial
effusion in a group of 76 patients with hypothyroidism of different severities, admitted in the
Clinic of Endocrinology between june 2009 – june 2011. All subiects had first an
endocrinologic examination followed by a cardiology one. We found out that the
pericarditis, independent of its severity, regress under hormone replacement therapy so
that no surgical intervention was needed in our study group.
Keywords:
.
Rezumat:
În cazul pacienþilor hipotiroidieni incidenþa revãrastului pericardic variazã între 3% ºi 80%, în
corelaþie cu severitatea ºi durata disfuncþiei tiroidiene. Acest lichid este deobicei în
cantitate micã sau moderatã ºi este bogat în mucoplisaharide ºi cholesterol. Am studiat
incidenþa ºi evoluþia revãrsatului pericardic într-un grup de 76 pacienþi cu hipotiroidie de
severitate diferitã, internaþi în Clinica de Endocrinologie în perioada iun. 2009 – iun. 2011.
Toþi subiecþii au avut mai întâi un examen endocrinologic urmat de unul cardiologic. Am
observant ca pericardita, independent de severitatea ei, regreseazã sub terapie hormonalã
de substituþie, astfel încât nu a fost necesarã nici o intervenþie chirurgicalã în lotul nostru.
Cuvinte cheie:
.
Correspondence to:
Cristina Tudoran,
Cardiology Department, Clinical County Emergency Hospital Timisoara,
10 Iosif Bulbuca Street, Timisoara
The incidence of pericardial effusions in patients in
mild hypothyroidism ranges from 3% to 6%, but in those
with severe deficiency the incidence ranges from 30% to
80%. However, pericardial effusions have also been
associated with subclinical hypothyroidism.(2)
Hypothyroidism can induce accumulation of effusions
in various body cavities including the peritoneum,
pericardium, pleura, middle ear, uvea, joints and scrotum.
These have the character of an exudates and the
incriminated physiopathological mechanism is mainly
extravasation of hygroscopic mucopolysaccaride into the

ody cavities combined with increased capillary
permeability, decreased lymphatic drainage, and
increased retention of salt and water. The serum and
effusions in patients with hypothyroidism usually have
high levels of cholesterol.
AIM OF THE STUDY
The aim of the study was to determine the incidence of
pericardial effusion in hypothyroid patients. We also tried
to establish if there is any correlation between the
severity of the thyroid disorder, expressed through the
level of thyroid hormones and the severity and evolution
of pericarditis.
MATERIAL AND METHOD
Our study group consisted of 76 patients with
hypothyroidism admitted in the Clinic of Endocrinology of
the County Emergency Hospital Timisoara, in a period of
3 years, between june 2009 – june 2011. In the study
group there were 67 women and 9 men, aged between
21 and 79 years (mean age= 42,21±23 years), 64 with
overt forms of hypothyroidism and 12 with subclinical
disease.
All the patients had first an endocrinologic
examination, which consisted of hormonal
determinations (thyroid stimulating hormone - TSH, free
thyroxin - FT4, free triiodothyroxin - FT3) and sonography,
in order to establish the etiology and severity of the
thyroid disorder. Subsequently, they where evaluated by
the cardiologist: history, physical examination, ECG,
chest x-ray and echocardiography done with an Acuson
Sequoia C512 echocardiograph. On the
echocardiographic examination, we assesed the
Table 1. Results of laboratory examinations.
Results of laboratory
examination in 76 patients
• Chest X-ray:
cardiomegaly
• ECG: negative T wave
ST segment changes
• Pericardial effusion:
Small
Moderate
Large
• Tendency to diastolic right ventricular collapse
• Swinging heart
• Thickened pericardium
dimensions of the heart cavities, left ventricular function,
the existance and degree of valvular disfunctions. We
tried to establish the presence pericardial effusion, the
volume and, if possible to appreciate the density of the
effusion. With this examination the hemodynamic
consequences and the presence or absence of
tamponade were determinate.
RESULTS AND DISCUSSIONS
The etiology of hypothyroidism was in most of the
cases autoimmune 71 patients (93.42%), 5 patients
(6.57%) had iatrogenic forms (after subtotal or total
thyroidectomy) and 1 patient (1.31%) had congenital
mixedema. Considering the severity of the symptoms
and level of TSH and thyroid hormones the patients were
divided in 3 subgroups: 12 patients (15.78%) with
subclinical hypothyroidism (elevated TSH, but normal
peripheric thyroid hormones), 12 patients (15.78%) had
overt hypothyroidism and 52 patients (68.42%) had
mixedema.
All patients underwent clinic and laboratory
examinations and the results are presented in table1.
We found that pericardial effusions in hypothyroidism
had an insidious onset, appeared without significant
hemodynamic changes, and echocardiography was the
primary method of diagnosis. EKG characteristics of
pericardial effusions included low QRS voltage,
PR-segment depression, ST-segment deviation, T-wave
changes and electrical alternans.
The incidence of pericarditis in the 3 subgroups as
presented in fig 1 is: 3 subjects (25%) from the patients
with subclinical hypothyroidism had small pericardial
effusions, 4 patients (30%) from those with overt disease
12 P Subclinical
hypothyroidism
12 normal
1
3 - 25%
3
12 P with overt
hypothyroidism
11 normal
1 (mild)
1
1
4 - 30%
2
2
1
52 P with
mixedema
24 normal
28
12
15
32 – 61.53%
18
8
6
4
3
8
177

had mild and moderate pericarditis, but 32 patients
(61.53%) with mixedema had pericarditis of different
severity. Most of them 56.25% had small effusions, 25%
had moderate forms and only 6 patients (18.75%) had
large effusions, 4 of them with incipient signs of
tamponade, wich remitted under hormone replacement
therapy, so that no pericardocentesis was needed.
Except for patients with prolonged hypothyroidism,
pericardial effusion was minor or moderate and the
cardiac symptoms are alleviated with hormonal
replacement therapy. Occasionally, pericardial effusion
was substantial and cardiomegaly was evident on chest
X-ray.
A peculiar aspect, found mostly in patients with
mixedema was a thickened pericardium. This aspect was
found in 25% of the patients and was probably caused by
long lasting or/and repeated episodes of mixedematous
pericarditis.
Pericardial effusion tends to regress slowly and
disappear several weeks or months after the patients
were reverted to euthyroid status.(3) Repeated
178
Fig. 1. Incidence of pericardial effusion in the 3 subgroups.
Fig. 2. Regression of pericardial effusion under replacement therapy.
echocardiographic examination performed after 1, 3 and
6 month of replacement hormonal therapy revealed
graduate reduction of pericardial effusion in concordance
with the improvement of the thyroid dysfunction as
presented in fig2.
Pericardial tamponade is a rare presentation of
hypothyroidism and has been found in most cases only
after many years of symptomatic hypothyroidism or in
patients who did not respond well to replacement
therapy.(4) It has been thought that the size of the
pericardial effusion depends on the severity and duration
of hypothyroidism and most cases of tamponade have
been reported in the elderly.
However, hypothyroid patients with hemodynamically
significant pericardial effusions may not always have
prominent symptoms and signs of hypothyroidism, such
as weight gain, weakness, edema, slow mentation etc.
The diagnosis of hypothyroidism in the elderly is difficult
because of its slow onset, and the clinical signs and
symptoms are usually subtle and non-specific.

CONCLUSIONS
1. The etiology of hypothyroidism was in most
of the cases autoimmune;
2. The incidence and amount of pericardial
effusion in mixedema correlates with the severity and
duration of disease;
3. Pericardial effusion due to hypothyroidism
regresses slowly under hormonal replacement therapy;
4. Sometimes a thickened pericardium was
found mostly in patients with mixedema.
References:
1. Gregory A, Brent P, Larsen R, et al. In: Kroneberg (ed), Williams’ Textbook of Endocrinology. 11th ed, Philadelphia, W. B.
Saunders Co., 2008; pp. 384-387.
2. McDermott MT. In the clinic. Hypothyroidism. Ann. Intern. Med. 2009; 151: ITC61.
3. Wei-Syun Hu, Shin-Huang Lee, Chung-Yen Huang: Massive Amount of Pericardial Effusion Secondary to Hashimoto’s
Thyroiditis: A Case Report. Formos J Endocrin Metab 2009; 1: 29-32
4. Klein I, Danzi S. Thyroid disease and the heart. Circulation 2007; 116: 1725–35.
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