Cardiac tamponade under thyroid hormone replacement therapy in a patient with empty sella syndrome.

P effusion is a common manifestation of hypothyroidism, observed in approximately 1/3 of patients without replacement therapy.1 In hypopituitarism, pericardial effusion is usually due to hypothyroidism, however, cardiac tamponade is a very rare complication of both hypothyroidism and adrenal insufficiency.2-4 Herein, we report a case of hypopituitarism with myxedema and pericardial effusion, in which cardiac tamponade developed under thyroid hormone replacement therapy. After 11 days of replacement therapy, cardiac tamponade was unexpected, and concomitant adrenal insufficiency was thought to be the cause. Interestingly, adrenocortical hormones were being closely monitored and cardiac tamponade was the first manifestation of adrenal failure. A 62-year-old male, with no history of previous disease was admitted to the hospital with a symptom of slow movements, malaise, and edema in extremities. His vital signs were normal. On physical examination, coarse hair, dry skin, nonpitting edema in lower extremities, and distant heart sounds were prominent. The thyroid gland was firm but not enlarged. Electrocardiogram showed low voltage in all derivations and chest x-ray (CXR) revealed cardiomegaly. The finding of the laboratory examinations were free: T3 (fT3 0.1 pg/ml [1.5-4.7 pg/ml]), and T4 (fT4 0.4 ng/dl [0.7-1.9 ng/dl]) were very low; surprisingly, thyroid stimulating hormone (TSH) was increased mildly (24.2 IU/ml [0.35-5 IU/ml]). AntiM [4000 IU/ml (0-115)] and anti-thyroid peroxidase [2329 IU/ml (0-34)] antibody levels were positive in high titers. Cortisol levels were measured by chemiluminescence assay method using bioDiagnostic Products Corporation (Llanderis, UK), Immulite 2000 immunoassay analyzer. The adrenocorticotropic hormone (ACTH) level was 29.36 pg/ml (6-57 pg/ml) and cortisol level was normal. Follicle stimulating hormone, luteinizing hormone, and testosterone levels were also low. Oral T3 and T4 and intramuscular testosterone replacement treatments were started immediately. Simultaneous echocardiography showed a massive pericardial effusion without the signs of cardiac tamponade