Diagnosis Dilemma; Patient with Breathlessness & Befogged Appearing Cardiomegaly on Chest Xray

Abstract

A sixty-year-old south Indian woman complained of dyspnoea on excretion, unexpected weight gain and other symptoms and signs of hypothyroidism that had been present over a year. When examined physically, the blood pressure was 110/70mmg. The heartbeat was regular at 82beats/min and oxygen saturation at room air was 96%.

The point of highest impulse was found to be in the fifth intercostal space, 10 cm to the left of the midsternal line, on examination there was no murmur or friction rub audible, and the heart sounds were within normal limits. Ankle oedema, rales, or hepatomegaly were absent. Thyroid function test showed the following values FT3 1.2 pg/ml FT4 0.5 ng/dl TSH 10 micro IU/ml and patient was started on T. Thyroxine 50 mcg/day Chest Xray showed an expanded cardiac silhouette on the right side at the junction of diaphragm and heart (Fig. 1). At the time, differential diagnosis made were myocarditis, pericarditis, or pericardial cyst. The ECG showed no abnormalities. HRCT scan visualized a radiolucent border around a centrally located, normal-sized heart shadow measuring several centimetres in thickness. This radiolucency was indicative of a significant fat build-up in the tissues surrounding the heart. 2dEcho showed pericardial fat deposition with EF 62% and NRWM. Pulmonary Function Test (PFT) was done it showed restrictive pattern.

Ultimately, the clinical impression was made that hypothyroidism was the cause of the patient's symptoms. It was suggested that the dyspnea was brought on by weakened muscle tone occurring as sequelae to hypothyroidism and the rapid increase in weight gain could have contributed to the increase in pericardial fat.