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the occurrence of pericardial effusion in hypothyroidism appears to be dependent on the severity of the disease .
pericardial effusion ( pe ) may be a frequent manifestation in myxedema , an advanced severe stage , as previously found , but is rarely associated with mild hypothyroidism .
the recent studies , concluded that pe is extremely infrequent in hypothyroidism , with an incidence of 3% to 6% . to our knowledge ,
about 20 cases of hypothyroid with cardiac tamponade have been reported in the literature.cardiac tamponade is usually a consequence of increased pericardial pressure with accumulation of pericardial effusion .
pericardial effusion may be caused by acute pericarditis , tumor , uremia , hypothyroidism , trauma , cardiac surgery , or other inflammatory / noninflammatory conditions .
it is important to suspect cardiac tamponade when patients have hemodynamic compromise regardless of the amount of pericardial effusion .
a 45-year - old female was brought by her relative to emergency department ( ed ) with history of shortness of breath for 2 days .
patient was apparently asymptomatic 2 months back ; when she gradually started noting malaise , lethargy , slow speech , edema of the face and extremities , and progressive weight gain .
vital signs on admission were recorded ( temperature , 36c ; blood pressure , 90/52 mmhg ; heart rate , regular at 74 beats / min ) .
patient was hypothermic with pulsus paradoxus ( inspiratory fall in systolic blood pressure > 10 mmhg ) .
physical examination found facial edema , coarse hair , dry skin , an engorged jugular vein , mild pallor , and non - pitting edema of the extremities .
the heart sounds were soft and distant with bilateral basal rales in both lung fields . on per abdomen examination , there was mild hepatomegaly .
bedside echocardiogram demonstrated small heart size with massive pericardial effusion and signs of early diastolic right ventricular ( rv ) collapse .
there was swinging motion of heart within large effusion , prominent respiratory alteration of rv dimension with right atrial ( ra ) and rv collapse during diastole .
pericardial effusion was all around and all cardiac chambers were of small size with predominant diastolic heart failure [ figure 2 ] .
considering echocardiographic findings and clinical scenario , diagnosis of large pericardial effusion with cardiac tamponade was made .
water bottle  configuration two - dimensional transthoracic echocardiogram showing large , all around pericardial effusion with right ventricular collapse in diastole , a subtle sign of cardiac tamponade immediately , we shifted the patient to intensive care unit for pericardial fluid tapping procedure ( pericardiocentesis ) .
we tapped about 450 ml of pericardial fluid through standard xiphisternal route under cardiac monitoring .
immediately after pericardial fluid tapping , the patient showed significant improvement in the cardiopulmonary status .
post pericardiocentesis , two - dimensional echocardiogram revealed minimal pericardial effusion with no evidence of tamponade .
considering her history and findings , we did thyroid function test for this patient , which was suggestive of primary hypothyroidism with high thyroid - stimulating hormone ( tsh ) and very low t3 and t4 levels .
the patient was treated with thyroxine 100 g daily which was later increased gradually to 200 g daily .
the patient 's condition improved and she was discharged in a good general condition after 2 weeks .
follow - up echocardiogram after a period of 3 months showed near total resolution of pericardial effusion . within a few weeks
hemoglobin ( hb ) , 11.5 g% ; erythrocyte sedimentation rate ( esr ) , 24 at the end of 1 hour ; total leukocyte count , 9850 mm ; platelet count , 2.1 lac ; blood urea level ( bul ) , 24 mg% ; serum creatinine level , 1.1 mg% ; liver function test ( lft ) , within normal limits .
thyroid function test : serum tsh , 84 mu / ml ( normal 0.355.5 mu / ml ) ; t3 , 26.2 ng / dl ( normal 90190 ng / dl ) ; and t4 , 0.56 g / dl ( normal 512 g / dl ) .
lipid profile : total cholesterol , 317 mg / dl ; high - density lipoprotein cholesterol ( hdl - c ) , 52 mg / dl ; triglyceride , 214 mg / dl .
cardiomegaly with globular enlargement of the cardiac silhouette with  water bottle  configuration figure 1 was seen .
electrocardiogram showed heart rate of 74/min with low voltage pattern with electrical alternans ( alternating size of qrs complex due to swinging of heart ) .
there was massive pericardial effusion ( about 600700 ml ) and signs of early diastolic rv collapse .
there was swinging motion ( apical-4-chamber view ) of heart within large effusion ; prominent respiratory alteration of rv dimension with ra and rv collapse during diastole ( parasternal long axis view ) was seen .
pericardial effusion was all around and all cardiac chambers were of small size with predominant diastolic heart failure .
left ventricular ( lv ) systolic function was normal with an overall lv ejection fraction of 60% [ figure 2 ] .
 effusion ) ; lymphocytes , 810/mm ; proteins , 4.7 g% ; sugar , 80 mg% and cholesterol , 192 mg% ; no organisms were grown on culture .
hemoglobin ( hb ) , 11.5 g% ; erythrocyte sedimentation rate ( esr ) , 24 at the end of 1 hour ; total leukocyte count , 9850 mm ; platelet count , 2.1 lac ; blood urea level ( bul ) , 24 mg% ; serum creatinine level , 1.1 mg% ; liver function test ( lft ) , within normal limits .
thyroid function test : serum tsh , 84 mu / ml ( normal 0.355.5 mu / ml ) ; t3 , 26.2 ng / dl ( normal 90190 ng / dl ) ; and t4 , 0.56 g / dl ( normal 512 g / dl ) .
lipid profile : total cholesterol , 317 mg / dl ; high - density lipoprotein cholesterol ( hdl - c ) , 52 mg / dl ; triglyceride , 214 mg / dl .
cardiomegaly with globular enlargement of the cardiac silhouette with  water bottle  configuration figure 1 was seen .
electrocardiogram showed heart rate of 74/min with low voltage pattern with electrical alternans ( alternating size of qrs complex due to swinging of heart ) .
there was massive pericardial effusion ( about 600700 ml ) and signs of early diastolic rv collapse .
there was swinging motion ( apical-4-chamber view ) of heart within large effusion ; prominent respiratory alteration of rv dimension with ra and rv collapse during diastole ( parasternal long axis view ) was seen .
pericardial effusion was all around and all cardiac chambers were of small size with predominant diastolic heart failure .
left ventricular ( lv ) systolic function was normal with an overall lv ejection fraction of 60% [ figure 2 ] .
 effusion ) ; lymphocytes , 810/mm ; proteins , 4.7 g% ; sugar , 80 mg% and cholesterol , 192 mg% ; no organisms were grown on culture .
the pathophysiologic derangements responsible for the collection of fluid in the serous cavities of hypothyroid patients are probably increased systemic capillary permeability and disturbances in electrolyte metabolism .
alexander first used the term  gold paint effusion  to describe the golden brown appearance of the pericardial fluid due to the shimmering satin cholesterol crystals .
the high cholesterol content of the fluid has been attributed to disturbances in lipid metabolism ; possibly , a churning action of the heart plays a role in the precipitation of cholesterol from pericardial fluid or the poor absorptive capacity of the pericardium may be a major factor.[35 ] thyroid replacement alone is sufficient for resolution of these effusions , although it may take many months .
this rare but significant condition should be considered , especially when it occurs after acute cold exposure .
pericardial effusion , lipid metabolic abnormality and abnormal liver function can be easily reversed with thyroid replacement .
cardiac tamponade is life - threatening , slow or rapid compression of the heart due to the pericardial accumulation of fluid , pus , blood , clots , or gas , as a result of effusion , trauma , or rupture of the heart .
less common causes include tuberculosis , acute myocardial infarction ( mi ) , pericarditis , radiation damage , bacterial infection , cardiomyopathy , lupus , dissecting aortic aneurysm , etc .
retnam et al . , chou et al . , chatterji et al . , lin et al . , al - mahroos et al . , and usalan et al .
cardiac tamponade is one of the life - threatening conditions that clinicians should have high degree of suspect in relevant clinical scenario .
bedside echocardiography is one of the gold standard investigations to diagnose pericardial effusion with cardiac tamponade .
hypothyroidism presenting with massive pericardial effusion with cardiac tamponade is an uncommon presentation as in the present case report .
how rapidly pericardial fluid gets accumulated is more important as per as cardiac hemodynamics is concerned rather than the volume of effusion .
mild pericardial effusion does respond to thyroxine supplementation over a long period and pericardiocentesis is necessary only when tamponade develops .
pericardial effusion is frequently found in patients with hypothyroidism , but it is rarely associated with cardiac tamponade . 
 hypothyroidism complicated by cardiac tamponade is rarely referenced in the medical literature . here 
 we report an unusual case of a 45-year - old female , who presented with breathlessness and was found to have hypothyroidism with large pericardial effusion with cardiac tamponade . 
 treatment included an emergency pericardiocentesis followed by thyroxine hormone replacement .