Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 614  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::  Article in PDF (61 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  What is the Poss...
 ::  What are the Pos...
 ::  What is the Diag...
 ::  What are the Cau...
 ::  What are the Car...
 ::  Is Cardiac Tampo...
 ::  What are the les...
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed9503    
    Printed134    
    Emailed4    
    PDF Downloaded343    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


 


 
GRAND ROUND CASE
Year : 2008  |  Volume : 54  |  Issue : 3  |  Page : 225-227

A young lady with hypotension and engorged neck veins


Department of Medicine, University College of Medical Sciences, Delhi, India

Correspondence Address:
V Sharma
Department of Medicine, University College of Medical Sciences, Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.41809

Rights and Permissions




How to cite this article:
Aggarwal A, Sharma V, Agarwal M P, Giri S. A young lady with hypotension and engorged neck veins. J Postgrad Med 2008;54:225-7

How to cite this URL:
Aggarwal A, Sharma V, Agarwal M P, Giri S. A young lady with hypotension and engorged neck veins. J Postgrad Med [serial online] 2008 [cited 2019 Jul 16];54:225-7. Available from: http://www.jpgmonline.com/text.asp?2008/54/3/225/41809


A 25-year-old woman presented to us with history of breathlessness. The lady had noticed progressively increasing fatigue in the past six months and had a sense of generalized weakness. Over the past week or so she had been unable to do even routine chores at home and had been breathless since the past two days. The dyspnoea increased with lying down. She denied any history of fever.

She appeared pale, had dry skin and sparse pubic and axillary hair. Her neck veins were engorged. She had a pulse rate of 86/min, blood pressure of 76/40 mm Hg. Pulsus paradoxus was absent. Her chest was clear and heart sounds were distant.


 :: What is the Possible Diagnosis? Top


The presentation of the case suggests a subacute to chronic process. The history of orthopnea, engorged neck veins and hypotension indicate a cardiac pathology. The features of engorged neck veins, hypotension and muffled heart sounds constitute the classical Becks' triad of cardiac tamponade. [1]

A chest roentgenogram revealed massive cardiomegaly. Electrocardiogram revealed low voltage complexes. An echocardiography revealed pericardial effusion with features of cardiac tamponade with collapse of the right atrium and ventricle in diastole. An urgent pericardiocentesis was performed and around 350 ml fluid removed. The condition of the patient improved.


 :: What are the Possible Causes of Cardiac Tamponade in This Patient? Top


The classical Beck's triad is not usually seen in slow-developing effusion. However, the presence of pallor, dry skin and prolonged progressive fatigue suggest a long-drawn process. The possibilities to be considered in chronic pericarditis include chronic infections (tuberculosis, fungal), neoplastic (lymphoma, metastasis from breast, lung), uremia, myxedema, collagen vascular diseases (systemic lupus erythematosus (SLE), rheumatoid arthritis, scleroderma), severe chronic anemia, chylopericardium etc. [1]

In this patient in view of the chronic nature of complaints, tuberculosis is a distinct possibility. The presence of dry hairless skin suggests a possibility of hypothyroidism. However, pericardial effusions secondary to hypothyroidism only rarely result in tamponade. [1],[2] Although tamponade is rare in SLE, cases of patients of SLE actually presenting with tamponade are known. [3] Even drug-induced SLE has occasionally presented with tamponade as first manifestation. [4] In view of her young age collagen vascular disease can be a possibility. Also tamponade can be the presentation of a yet occult malignancy. [1]

Investigations revealed Hb- 9.8 gm/dL, total leucocytes of 9800 with 75% polymorphs and 23% lymphocytes. ESR was 32. Red blood cells were normocytic and normochromic. Liver and renal function tests were normal. The serum Na + was 132, serum K + was 3.7 and serum Ca 2+ was 9 mg/dL. The pericardial fluid of the patient was slightly yellow. Pericardial fluid examination revealed proteins of 4.1 g%, sugar 42 mg% and total cells 50/ml predominantly lymphocytes. No atypical cells or cholesterol crystals were observed. Gram and AFB staining, culture and PCR for mycobacterium were negative. Adenosine deaminase levels were 6 IU/ml.

The patient said that she was amenorrhoeic since her last childbirth four years back. She had delivered a child at her home four years back and had needed hospitalization for severe postpartum bleeding. Following this she had a failure of lactation and had not had a pregnancy ever since. She also complained of loss of libido, hair loss, increasing fatigue.


 :: What is the Diagnosis in This Patient? Top


The history of postpartum bleeding suggests Sheehan's syndrome. The classical history of lactational failure followed by failure of menstruation virtually clinches the diagnosis of Sheehan's syndrome. [5]

The manifestations in this are believed to result from the postpartum necrosis of pituitary due to postpartum haemorrhage. This is because of higher blood supply needed by pituitary as a result of physiological hypertrophy during pregnancy. However, evidence suggests a role of autoimmune response to sequestered antigens released as a result of pituitary necrosis in the causation of Sheehan's syndrome. This ongoing autoimmune phenomenon explains the late presentation of Sheehan's in the form of circulatory collapse (hypocortisolism and hypothyroidism) occurring long after the initial manifestations of acute loss of pituitary function (agalactia and amenorrheic). In fact it has been seen that a higher percentage of patients with Sheehan's syndrome had pituitary antibodies as compared to controls. [6]

Sheehan's syndrome can present with variable manifestations depending on the involvement of the pituitary. The features may include postpartum lactational failure and amenorrheic, fatigue, weakness, hair loss, fine wrinkles around face, loss of libido, polyuria, hypoglycemia and hypotension etc. [5]

Her hormonal studies revealed a serum TSH-0.6 (0.35-5.5 mU/L), serum free T3- 0.8 (2.3-4.2 pg/mL), serum free T4-0.2 (0.9-2.80 ng/dL), serum FSH-4.75 (23-116 IU/L), serum LH-1.83 (15.9-54.0 U/L), serum cortisol (8 AM morning)-1(5-23 ug/dL). These are consistent with the possibility of panhypopituitarism. The serum TSH can be normal, low or sometimes raised in central hypothyroidism. Adrenocorticotropic hormone is usually low (not available in our patient).


 :: What are the Causes of Panhypopituitarism? Top


The possible causes to be considered in this patient apart from Sheehan's include lymphocytic hypophysitis or other infiltrative diseases, pituitary adenomas or a parasellar mass, tuberculosis or rarely, empty sella syndrome. Magnetic resonance imaging of the brain using gadolinium contrast revealed a normal pituitary, sella and parasellar region. Imaging in Sheehan's usually reveals an empty sella of normal size although enlarged or partially atrophied pituitary may be seen depending on the stage of the disease. Rarely, as in the present case, sella can be normal [Figure 1]. [5] Although some authors have suggested a correlation between the amount of pituitary remnants and hormonal secretory capacity this does not appear to be true in this case. [7]


 :: What are the Cardiac Manifestations of Hypothyroidism and are They Different in Primary and Central Hypothyroidism? Top


Cardiac manifestations of hypothyroidism include sinus bradycardia, diastolic hypertension, narrow pulse pressure, pericardial effusions, coronary artery disease etc. Pericardial effusions although common with primary hypothyroidism, are rare in central hypothyroidism. [2] Hypothyroidism-related pericardial effusions are usually clear and straw colored. Occasionally they may be yellow (gold paint) due to cholesterol pericarditis. [8] They only rarely cause tamponade even in primary hypothyroidism. Usually, the hypothyroidism in Sheehan's syndrome is less severe than in primary hypothyroidism. [5] This patient presented with features of cardiac tamponade which was confirmed on echocardiography.


 :: Is Cardiac Tamponade Described with Sheehan's Syndrome? Top


Cases of Sheehan's syndrome presenting as tamponade have been reported earlier. [8],[9],[10] Cardiac tamponade is rare with hypothyroidism due to earlier detection of hypothyroidism. But in cases presenting late this can be seen. Cardiac tamponade occurs when the amount of fluid in the pericardium is sufficient to restrict the inflow of blood into the ventricles. The amount of fluid necessary to cause tamponade varies with the rapidity of development of effusion. In hypothyroidism, since the process is slow, tamponade is unusual. In such cases tamponade can develop slowly and may mimic heart failure with features of dyspnea, orthopnea, tender hepatomegaly. [1] In Sheehan's syndrome the presence of low cortisol may result in low-pressure tamponade. In low-pressure tamponade, usually occurring in hypovolemia, the features can be subtle and easily missed. Here the jugular venous pressure is usually normal or only slightly elevated, the arterial pressure is normal and pulsus paradoxus usually absent. [2],[8]


 :: What are the lessons from this case? Top


With two-thirds of deliveries occurring at home and the poor state of obstetric and general healthcare, Indian women are at a significant risk of developing Sheehan's syndrome. Although not much literature is available about the epidemiology of Sheehan's syndrome, a study in Kashmir valley projected that more than 3% of all parous women ≥20 years might be having Sheehan's syndrome. Very often these women present late with life-threatening complications as in our case. [11]

This case indicates the need to consider hypothyroidism, even central, as a possible etiology in patients with unexplained pericardial effusion. Since Sheehan's can present at a variable duration after the last pregnancy it has to be considered even if history of childbirth is remote. Lactational failure is seen in most severe cases of Sheehan's syndrome. Therefore follow-up of patients of postpartum haemorrhage for development of lactational failure may help in preventing more serious late complications like hypothyroidism and hypocortisolism.

The management consists of management of anemia, hypotension, hypoglycaemia and any other complication. Adequate replacement of deficient hormones should be done. With appropriate hormone replacement most patients make a complete recovery over a variable duration. However, the worsening of tamponade with thyroxine replacement has been seen occasionally and is due to precipitation of cholesterol crystals leading to cholesterol pericarditis. This emphasizes the need for adequate monitoring during therapy. [8] In severe cases and in the presence of fluid depletion treatment should be on lines of adrenal crisis. It is important to start steroids prior to thyroxine replacement because thyroxine replacement can lead to adrenal crisis by enhancing the metabolism of glucocorticoids and increasing the metabolic needs of the body. [12]

After the initial pericardiocentesis the lady was put on hormone replacement including stepwise uptitrated thyroxine and hydrocortisone was initiated. The patient improved remarkably and the cardiomegaly disappeared [Figure 2]. The patient is still on regular follow-up.

 
 :: References Top

1.Braunwald E. Pericardial disease. In: Kasper DL, Braunwald E, Fauci A, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 16 th ed. New York: McGraw Hill; 2005.p.1414-20.  Back to cited text no. 1    
2.Larsen PR, Davies TF. Hypothyroidism and thyroiditis. In : Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, editors. Williams textbook of endocrinology. 10 th ed. Philadelphia: Saundres; 2003. p. 423-55.  Back to cited text no. 2    
3.Abraham GE 3rd, Thorne KD, Moore CK. Tamponade precedes diagnosis of systemic lupus erythematosus. Am J Med Sci 2006;331:162-3.  Back to cited text no. 3    
4.Verma SP, Yunis N, Lekos A, Crausman RS. Carbamazepine-induced systemic lupus erythematosus presenting as cardiac tamponade. Chest 2000;117:597-8.  Back to cited text no. 4    
5.Kele?timur F. Sheehan's syndrome. Pituitary 2003;6:181-8.  Back to cited text no. 5    
6.Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N. Pituitay autoimmunity in patients with Sheehan's syndrome. J Clin Endocrinol Metab 2002;87:4137-41.  Back to cited text no. 6    
7.Lee HC, Lee EJ, Lee KW, Ahn KJ, Jung TS, Kim DI, et al . Computed tomographic correlation with pituitary function in Sheehan's syndrome. Korean J Intern Med 1992;7:48-53.  Back to cited text no. 7    
8.Goswami R, Tandon N, Singh B, Shah P, Ammini AC. Circulatory collapse in a 30 year old amenorrheic woman. Postgrad Med J 1996;72:501-4.  Back to cited text no. 8    
9.Sahin I, Taskapan H, Yildiz R, Kosar F. Cardiac tamponade as initial presentation of Sheehan's Syndrome. Int J Cardiol 2004;94:129-30.  Back to cited text no. 9    
10.Tahir MZ. Cardiac tamponade in hypothyroidism due to Sheehan's syndrome. J Pak Med Assoc 1992;42:249-51.  Back to cited text no. 10    
11.Zargar AH, Singh B, Laway BA, Masoodi SR, Wani AI, Bashir MI. Epidemiologic aspects of postpartum pituitary hypofunction (Sheehan's syndrome). Fertil Steril 2005;84:523-8.  Back to cited text no. 11    
12.Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, Stalla GK, Ghigo E. Hypopituitarism. Lancet 2007;369:1461-70.  Back to cited text no. 12    


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 A woman with fatigue, dyspnoea, and orthopnoea
Sharma, V., Agarwal, M.P.
BMJ. 2010; 340(7748): 717
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow