Case Summary: A 52-year old male was admitted at the Intensive Care Unit of Ospital ng Makati due to difficulty of breathing. The patient is a diagnosed case of papillary thyroid carcinoma, S/P total thyroidectomy and radioactive iodine treatment (1997) maintained on levothyroxine 100 mcg OD with poor compliance. On admission, the patient had neck vein engorgement, bibasal crackles, muffled heart sounds, abdomen had shifting dullness and (+) fluid wave test, and grade 3 bipedal edema. 12-L ECG showed electrical alternans and chest x-ray revealed an enlarged heart with water bottle configuration. Echocardiography showed compressed right ventricle and right atrium, right atrium systolic indentation, and a large echo free space which signified cardiac tamponade. The patient was tachypneic and became hypotensive. Subxiphoid pleuropericardial window with pericardiocentesis was done draining a total of 1.8 liters serosanguinous fluid. Thyroid function tests showed elevated TSH (>40uIU/L), decreased F T4 (0.00ng/dL ) and F T3 (0.72pg/mL ) . levothyroxine 25 mcg OD was started and increased to 50 mcg after three days. Pericardial fluid showed predominance of lymphocytes and had high protein content. The dyspnea was relieved and patient had increased urine output and decreased edema after the pericardiocentesis. Repeat 12-L ECG four hours after pericardiocentesis showed resolution of the electrical alternans. Repeat 2D-Echo with Doppler after several days showed mild pericardial effusion. Repeat thyroid function tests showed normal FT4 and FT3 levels and increased TSH (34.5uIU/L). The patient was discharged improved maintained on levothyroxine 100 mcg OD and had no recurrence of the cardiac tamponade. Conclusion: Cardiac tamponade is a rare complication of hypothyroidism. A high index of suspicion is needed for prompt diagnos i s of cardiac tamponade and hypothyroidism followed by immediate intervention. Pericardiocentesis is necessary and hormonal treatment with levothyroxine is crucial as it produces satisfactory clinical outcome with reduction in recurrences of the cardiac tamponade after drainage is performed.

BACKGROUND: Acute renal infarction often presents with abdominal  pain,  nausea,  vomiting,  and  fever.With other more common illnesses presenting with the same symptoms,
it is often misdiagnosed leading to delayed treatment.We present a case of a young female diagnosed to have Membranous Glomerulopathy who presented with sudden onset  flank  pain  in  whom was initially treated as urinary tract infection.
CASE: A  19-year-old  female  diagnosed  with  membranous glomerulopathy presented at the Emergency Room (ER) with severe,  right  sided,  flank  pain  of  acute  onset,  associated with nausea and vomiting. No fever, dysuria, hematuria, or history of trauma. Her vital signs were within normal range. Abdominal  examination  revealed  a  distended  but  soft non-tender  abdomen  with  positive  shifting  dullness and fluid wave test. Right sided costovertebral angle tenderness was  elicited.Initial diagnostics showed leukocytosis with neutrophilic  predominance,  serum  creatinine  of  0.77mg/dL,  and  proteinuria  of  >600mg/dL.Abdominal  ultrasound showed  non-specific  findings,  thus  contrast-enhanced  computed  tomography  scan  (CT-Scan)  of  the  abdomen was  done which revealed areas of non-enhancement in the upper to middle portions of the right kidney which may relate to areas of ischemia and/or infarction, likely due to thrombosis involving the more distal portion of the right renal artery and massive ascites. Result was confirmed by computed tomography angiography (CTA) of the kidneys showing right renal artery thrombosis. Evaluations for other causes  of  renal  artery  thrombosis  aside  from  patient's concurrent  membranous  glomerulopathy  were  done  and were negative. Anti-coagulation therapy was initiated using low molecular weight heparin (LMWH) and was thereafter maintained on warfarin.
CONCLUSION: A  high  index  of  clinical  suspicion  is  needed to  diagnose  acute  renal  infarction  because  of  its  non-specific symptoms which can mimic other conditions. Early diagnosis and prompt initiation of anti-coagulation therapy is  important  to  avoid  irreversible  kidney  damage.  Acute renal infarction should be considered as a cause of acute onset flank pain in patients with risk factors and normal initial screening test.

Human ; Female ; Adult ; Glomerulonephritis, Membranous ; Heparin, Low-molecular-weight ; Warfarin ; Hematuria ; Creatinine ; Renal Artery ; Dysuria ; Leukocytosis ; Kidney ; Kidney Diseases ; Proteinuria ; Urinary Tract Infections ; Infarction ; Flank Pain ; Case Reports