Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine

ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20

A RARE CAUSE OF ASCITES: MYXOEDEMA ASCITES K Stinkens, E Vermeyen & G De Hondt To cite this article: K Stinkens, E Vermeyen & G De Hondt (2013) A RARE CAUSE OF ASCITES: MYXOEDEMA ASCITES, Acta Clinica Belgica, 68:5, 384-385 To link to this article: http://dx.doi.org/10.2143/ACB.3357

Published online: 06 May 2014.

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MYXOEDEMA ASCITES

Case Report

A RARE CAUSE OF ASCITES: MYXOEDEMA ASCITES Stinkens K1, Vermeyen E2, De Hondt G3 1

Internal Medicine, University Hospital Leuven, 2Department of Geriatric medicine, Maria Hospital Noord-Limburg, 3Department of Gastro-Enterology, Maria Hospital Noord-Limburg

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Correspondence and offprint requests to:  K. Stinkens, E-mail: [email protected]

ABSTRACT The case report describes an 88-year-old patient who presented with new-onset ascites. After excluding frequent causes of ascites, he was diagnosed with myx­ oedema ascites. Myxoedema ascites is rare. Analysis of ascitic fluid shows a high serum-ascites albumin gradient and a high protein level. Myxoedema ascites resolves completely after starting thyroid hormone replacement therapy. Key words:  ascites, hypothyroidism, myxoedema

INTRODUCTION Myxoedema ascites is a rare presentation of hypothyroidism and also a rare cause of ascites. Therefore there is a risk of delayed diagnosis. The diagnosis of myxoedema ascites should be considered when other more frequent causes are excluded and when there is biochemical evidence of hypothyroidism.

CASE REPORT An 88-year old man was referred to the emergency department with increasing fatigue, dyspnoea, oedema of the right leg and a distended abdomen for several months. His medical history included an amputation of his left leg because of a trauma, a recent ileocaecal resection because of chronic stenosis of the small bowel due to Crohn’s disease and a myocardial infarction. His current treatment consisted of 80 milligram acetyl salicylic acid (Asaflow) a day. He smoked two packs of cigarettes a week. He was a social drinker, but he had been drinking on a daily basis for years. The general

Acta Clinica Belgica, 2013; 68-5

practioner already tried treatment with diuretics. This resulted in a slight improvement of the oedema. Physical examination revealed a distended abdomen with shifting dullness. There were basal lung crackles, a systolic cardiac murmur and oedema of the right leg. The central venous pressure was normal. Laboratory tests showed a mild normochromic, normocytic anaemia, a normal INR, normal liver function tests, a low albumin level (2.8 g/dl) and a raised TSH level (171.2 mIU/l). Hepatitis serology was negative. Urine analysis was normal. Analysis of the ascitic fluid showed a white blood cell count of 113/µl with 80% lymphocytes. The total protein level was high (3.7 g/dl). Gram staining and cytology were negative. A chest radiograph showed no cardiomegaly or pulmonary oedema. Abdominal ultrasound and magnetic resonance imaging revealed no signs of cirrhosis, portal hypertension or peritoneal masses. Oesophagogastroscopy could not reveal evidence of portal hypertension (oesophageal varices or gastropathy). Cardiac ultrasound showed a normal left ventricular function, an aortic stenosis with a peak gradient of 25 mmHg and a small mitral insufficiency. There were no signs of cardiac failure. Because common causes of ascites were excluded and because an important hypothyroidism was diagnosed, the possibility of myxoedema ascites was considered. Raised thyroid peroxidase antibodies (231 IU/ml) and thyroglobulin antibodies (14964 IU/ml) confirmed the presence of a primary hypothyroidism, namely Hashimoto disease. Thyroid hormone replacement therapy was started with gradually increasing doses. Four weeks after discharge there was no clinical evidence of ascites anymore and the TSH level was decreasing.

DISCUSSION Hypothyroidism is a rare cause of ascites, occurring in 1-5% of patients with ascites. Furthermore ascites is a rare presenting symptom of hypothyroidism. Overall ­hypothyroidism often

doi: 10.2143/ACB.3357

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MYXOEDEMA ASCITES

presents insidiously (1-2). The pathophysiology of myxoedema ascites is supposed to be based on an increase in capillary permeability. This leads to the escape of a protein rich fluid into the extravascular component. Thereby ascitic fluid with an elevated protein level and a raised serum-ascites albumin gradient (SAAG) will form in the peritoneal cavity (3-4). The diagnostic work-up of a patient with new-onset ascites starts with a thorough medical history (including cardiac and respiratory anamnesis, gastro-intestinal anamnesis, weight loss, drug and alcohol abuse …) and physical examination (incl. distended abdomen with shifting dullness, cardiac and pulmonary auscultation, central venous pressure, peripheral oedema, presence of spider naevi, flapping tremor…). Necessary laboratory tests include a complete blood cell count, liver function, pancreatic function and renal function tests, prothrombin time, total protein and albumin, hepatitis serology, a urine-analysis and analysis of ascitic fluid. Necessary imaging studies include a chest ­radiograph, an ultrasound, computed tomography and or magnetic resonance imaging of the abdomen. Analysis of ascitic fluid is an essential tool to differentiate the several causes of ascites. Obligatory analyses include white blood cell count and differentiation, total protein level and albumin level to calculate the SAAG and distinguish whether the ascitic fluid is a transudate or an exudate. A high SAAG (> 1.1 g/dl) suggests that the ascitic fluid is a transudate and caused by portal hypertension with a diagnostic accuracy of 97% (including cirrhosis, congestive heart failure). A low SAAG (

A rare cause of ascites: myxoedema ascites.

The case report describes an 88-year-old patient who presented with new-onset ascites. After excluding frequent causes of ascites, he was diagnosed wi...
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