Tennessee Medicine E-Journal


A 43-year-old white female with a history of hypothyroidism and not on her thyroid replacement for a year, presented with irregular periods, weight gain, hoarse voice, hair loss and abdominal distention with dyspnea. Physical exam was significant for thin hair, dry skin, decreased reflexes, non-pitting edema in her extremities, distant heart sounds and dullness on abdominal percussion. Thyroid-stimulating Hormone (TSH) level was 55 and free T4 was less than 0.4ng/dL. Four liters of straw-colored fluid removed by paracentesis revealed exudative effusion with total protein 6gm/dL, fluid white blood cell count 795 cells/mm3, lymphocytes 58%. Further evaluation to exclude other causes of high-protein ascites was negative, including malignant cells, bacterial cultures, acid fast bacilli stain and culture, urine protein and antinuclear antibody. Echocardiogram showed normal cardiac function with a large pericardial effusion without tamponade. Ultrasound of the liver was negative, as well as CT scan of the abdomen and pelvis, except for a large amount of ascites.