An 81-year-old woman instanted with massive macroglossia and signs of the pair hypothyroidism and pericardial tamponade.

An 81-year-old woman instanted with massive macroglossia and signs of the pair hypothyroidism and pericardial tamponade. Drainage of the pericardial effusion produc dramatic resolution of the macroglossia. Marked elevation of central venous influence may result in macroglossia, possibly because of anomalous venous drainage of the tongue.

Early studies of overtly hypothyroid patients prompted that pericardial effusion was a relatively universal associated feature.[1,2] More recent echocardiographic studies of the hypothyroid population exhibit to a widely varying incidence of pericardial effusion from as grave as 3 percent to 88 percent No correlation appears to exist between progression in a continuously ascending gradation of pericardial effusion and severity or duration of hypothyroidism.[3,4] Available descriptions of hypothyroid-associated pericardial effusion propose that patients present far more commonly with signs and symptoms of the underlying endocrine disorder, rather than with sequelae of pericardial effusion.[5]

We describe a patient presenting with acute massive macroglossia and cardiac tamponade appropriate to a large pericardial effusion. Biochemical evaluation confirmed an initial impression of hypothyroidism. Drainage of the pericardial effusion originateed in dramatic resolution of the macroglossia.

Case Report

An 81-year-old woman at handed with a 6-h history of massive tongue swelling. Her medical history included chronic Congestive heart failure for which she regularly took captopril and furosemide. Clinically, dramatic macroglossia was apparent (Fig 1) and the tongue could not be retracted intra-orally. There was, however, no associated upper airway obstruction. Examination also revealed features of one as well as the other right-sided heart failure (pulsatile jugular venous constraining force elevated to 10 cm, hepatomegaly palpable 5 cm below the right subcostal margin, pitting ankle edema) and hypothyroidism (inappropriate bradycardia, los of external third of eyebrows, very slowly relaxing ankle jerks) Pulsus paradoxus of 25 mm Hg was not away The thyroid gland was impalpable. There were no features to hint superior vena caval obstruction. The chest radiograph showed a markedly enlarged cardiac silhouette with mild pulmonary venous congestion. Electrocardiogram showed sinus harmonious flow of 80 beats per minute and low-voltage complexe and nothing else Monitoring revealed no significant dysrhythmia. Echocardiography demonstrated a large circumferential echo-free space consistent with a significant pericardial effusion. There was evidence of right atrial collapse in late diastole. This finding was highly suggestive of cardiac tamponade. At this stage, the relationship of the macroglossia to the pericardial effusion was uncertain, still in view of obvious cardiac tamponade, pericardial drainage was performed. throughout the first 36 h, 1500 ml of serosanguineous fluid was drained with dramatic resolution of the two the macroglossia (Fig 2) and the signs of right heart failure. Cytologic examination of the fluid revealed no malignant lonely dwellings and culture of the fluid did not become greater [i]or[/i] larger any organism (including acid-fast bacilli). Thyroid function standards subsequently confirmed hypothyroidism: [T.sub.4], 24 [mu]mol/L (normal range, 60 to 150); released thyroxine index, 39 (60 to 150); and TSH 17 IU/L (<5); thyroxine therapy was commenc At follow-up 3 month later, she was clinically euthyroid, had no evidence of cardiac failure, and the tongue was normal.

Discussion

The lack of reaccumulation of pericardial fluid after initiation of thyroid replacement therapy forcibly supports the view that the initial presentation of cardiac tamponade was associated with hypothyroidism. This observation is of interest, as previous investigators have noted that despite treatment of hypothyroidism, the associated pericardial effusion may persist or recur[67] The unique feature of this case, however, was the patient's presentation with macroglossia and its following resolution with drainage of the pericardial effusion.

Although macroglossia is described in hypothyroidism,[8] its total resolution after pericardial drainage (before thyroxine therapy was started) argues firmly against it being a direct feature of the underlying endocrine disorder. The promptnes of its resolution in this patient implies that venous engorgement was the principally likely cause of the macroglossia. The venous drainage of the tongue is typically from the lingual vein into the facial vein and then into the internal jugular vein. That the tongue was enlarged without obvious associated facial or arm swelling is therefore difficult to explain. A possible explanation is the observation that the lingual vein may drain directly into the internal jugular vein,[9] although this is extremely rare. Impaired lymphatic drainage in hypothyroidism may be an additional contributory factor.[10] Central venous hurry may have gradually risen to a critical flush at which point lymphatic drainage was finally overbear and progressive lingual swelling ensu This would account for the short history of tongue swelling.

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