Case Report
A Case Report of Type B Acute Aortic Dissection with Massive Pericardial Effusion
Yuko Kumagai, Soki Kurumisawa, Kei Aizawa and Yoshio Misawa*
Division of Cardiovascular Surgery, Jichi Medical University, Japan
*Corresponding author: Yoshio Misawa, Division of Cardiovascular Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
Published: 30 Aug, 2016
Cite this article as: Kumagai Y, Kurumisawa S, Aizawa K,
Misawa Y. A Case Report of Type B
Acute Aortic Dissection with Massive
Pericardial Effusion. Ann Clin Case
Rep. 2016; 1: 1113.
Abstract
A 73-year-old man was transferred to our emergency room with a sudden onset of severe back pain, being under mechanical ventilation because of an intractable pain. His heart rate was regular and blood pressure was 166/96mmHg. A chest computed tomographic scan revealed a massive pericardial effusion associated with type B aortic dissection. His family told us that he had a history of hypothyroidism, and that he had stopped taking medicine several years prior by his judgment. Blood test revealed that thyroid stimulating hormone, free triiodothyronine, and free thyroxine level were 200.93μU/ml, 0.88pg/ml, and below 0.1ng/dl, respectively. We strongly suspected that hypothyroidism caused the chronic pericardial effusion without apparent hemodynamic relevance. To get a definite diagnosis of the effusion, we drained the effusion through the left antero-lateral thoracotomy, considering a subsequent pericardial fenestration to the left pleural cavity. Then, we confirmed that the pericardial effusion was caused by chronic hypothyroidism because of a yellowish and transparent fluid. Treatment for hypothyroidism was initiated postoperatively. The patient was doing well, without pericardial effusion and aortic enlargement, under a euthyroid condition 10 months after the surgery. In conclusion, getting his past history help we choose an adequate treatment in a type B dissection case associated with a massive pericardial effusion.
Keywords
Hypothyroidism; Pericardial effusion; Aortic dissection; Thyroid stimulating hormone; Free triiodothyronine; Free thyroxine
Introduction
Pericardial effusion appears followed by cardiac, aortic, pericardial, and other systemic diseases. Acute accumulation can cause cardiac tamponade associated with hemodynamic instability. By contrast, chronic fluid accumulation typically presents with limited clinical symptoms. Herein, we report a case of massive pericardial effusion associated with type B acute aortic dissection.
Case Presentation
A 73-year-old man was transferred to our emergency room with a sudden onset of severe back
pain. The patient could not get us his medical history, as he was under mechanical ventilation for
the intractable pain. However, his family told us that he had a history of hypothyroidism, but he
decided to stop taking medicine several years prior by his own judgment. No other past and family
histories were informed. Physical examination revealed normal heart sounds with no murmurs,
and normal breathing sounds. His heart rate was regular and blood pressure was 166/96 mmHg.
Electrocardiogram revealed a sinus rhythm with a heart rate of 48 beats per minute. A chest
computed tomographic scan revealed a massive pericardial effusion and type B aortic dissection
with a small amount of pleural effusion (Figure 1). No intimal flap was observed in the ascending
aorta and aortic arch. Dissection between the descending aorta and the bilateral common iliac
arteries was observed. Echocardiographic findings revealed a massive pericardial effusion without
paradoxical movements of the right heart showing cardiac tamponade and valve diseases.
Laboratory tests showed a c-reactive protein of 0.45mg/dl and a white blood cell count of 4,100/
μg. Other blood tests revealed creatine phosphokinase of 1038U/L, total cholesterol of 187mg/dl,
and triglyceride of 117mg/dl. In addition, thyroid stimulating hormone, free triiodothyronine,
and free thyroxine level were 200.93μU/ml, 0.88pg/ml, and below 0.1ng/dl, respectively. His stable
hemodynamic condition with the massive pericardial effusion prevented us from performing a
median sternotomy for drainage of the effusion. We chose a small left anterolateral thoracotomy
for drainage considering a subsequent pericardial fenestration to the left pleural cavity. The effusion
was yellowish and transparent. Then, we confirmed a chronic pericardial effusion induced by a long-standing hypothyroidism.
Treatment for systemic hypertension and hypothyroidism was
started postoperatively. The aortic dissection remained unchanged
in diameter and longitudinal range for two weeks. The patient was
transferred to another hospital for continued treatments for both
diseases. He was doing well, without pericardial effusion and aortic
enlargement, under a euthyroid condition 10 months after the
surgery.
Discussion
Heart failure, type A aortic dissection, and pericarditis can
produce accumulation of pericardial effusion, which can result in
hemodynamic deterioration because of its rapid progress. Systemic
diseases such as hypothyroidism, systemic lupus erythematosus, and
renal failure are also associated with pericardial effusion [1,2]. Slowly
developing pericardial effusion is seldom associated with clinical
symptoms. By contrast, rapid accumulation of the effusion can result
in cardiac tamponade even in a systemic disease [3,4].
Pericardial effusion is a common clinical manifestation in patients
with hypothyroidism, although it is often unrelated to disease severity
[5]. Dattilo et al. [5] reported a case of subclinical hypothyroidism
with a ubiquitous pericardial effusion. Subclinical hypothyroidism
is defined by elevated serum levels of thyroid stimulating hormone,
with normal levels of free thyroid hormones. Before surgery, our case
had a high level of creatine phosphokinase, but no clinical symptoms,
indicating hypothyroidism.
Acute aortic dissection can cause pericardial effusion
particularly in type A dissection [6]. Takagi et al. [7] reported a
case of hemopericardium in type B aortic dissection, with bloody
fluid collected via pericardiocentesis, suggestive of an intramural
hemorrhage that was unable to be detected by computed tomography,
as previously reported [8]. A chest computed tomographic scan of our
case showed type B aortic dissection with massive pericardial effusion.
Although his hemodynamic condition was stable, we drained the
effusion to provide a definitve cause of the fluid accumulation.
Figure 1
Figure 1
Preoperative chest computed tomographic scan (a-f).
A massive pericardial effusion and type B aortic dissection with a small amount of pleural effusion is shown. No intimal flap is observed in the ascending aorta and
aortic arch. The diameter of the dissected aorta is normal.
Conclusion
A 73-year-old man with a history of medical treatment for hypothyroidism presented with a sudden onset of severe back pain. A chest computed tomographic scan revealed a massive pericardial effusion and type B aortic dissection. Blood test for thyroid functions with his past medical history and the macroscopic findings of the effusion provided that the pericardial effusion was independent of the type B acute aortic dissection.
Authors’ Contributions
Y Kumagai, S Kurumisawa, and K Aizawa contributed to the study conception and design, acquisition, analysis, and interpretation of data, and drafting of the manuscript. Y Misawa critically revised the manuscript and provided final approval for publication.
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