以心包积液为首发症状的腺垂体功能减退延误诊断1例分析

Analysis of 1 Case of Delayed Diagnosis of Adenohypopituitarism with Pericardial Effusion as the First Symptom

摘要: 目的：分析一例腺垂体功能减退症合并大量心包积液致垂体危象患者的病例特点，讨论误诊原因。方法：对曾误诊1例腺垂体功能减退症合并大量心包积液致垂体危象患者的临床资料进行回顾性分析原因。结果：女性患者，57岁，因“气促、咳嗽2年，头晕、乏力1周”入院，患者2年前因气促、咳嗽在湛江市某三甲医院心内科住院诊断“大量心包积液、心衰、甲功异常”，对症治疗后好转，出院后未随诊。1周前出现头晕、乏力，活动后胸闷、心悸、气促，我院门诊测血压低至68/47 mmHg，血糖低至2.4 mmol/L，完善检查后诊断：腺垂体功能减退症、大量心包积液、垂体危象，治疗予氢化可的松300 mg qd治疗，逐渐减量，加用左甲状腺素钠片小量口服，同时抗感染、对症支持治疗，症状好转。出院后改为口服泼尼松上午10 mg，下午2.5 mg，左甲状腺素钠片50 μg qd。1个月后复查心包积液消失。结论：腺垂体功能减退患者以心包积液为首发表现，其临床表现缺乏特异性，容易漏诊，本例患者延误诊断至少2年，回顾其诊治经过发现主要误诊原因为：1) 临床医生缺乏对继发性甲状腺功能减退及腺垂体功能减退症的认识，未能及时完善检查以明确诊断指导治疗；2) 症状缺乏特异性；3) 患者依从性问题：对患者教育欠缺，患者未能按时复诊追查病因。

Abstract: Objective: To analyze the characteristics of a patient with adenohypopituitarism complicated by massive pericardial effusion and pituitary crisis, and to discuss the causes of misdiagnosis. Methods: The clinical data of a misdiagnosed case of adenohypopituitarism with massive pericardial effusion and pituitary crisis were analyzed retrospectively. Results: A 57-year-old female patient was admitted to hospital due to “shortness of breath and cough for 2 years, dizziness and weakness for 1 week”. The patient was admitted to the cardiology department of a Grade-III hospital in Zhanjiang City 2 years ago due to shortness of breath and cough and diagnosed with “massive pericardial effusion, heart failure and abnormal thyroid function”. The patient improved after symptomatic treatment, and was not followed up after discharge. Dizziness, weakness, chest tightness, palpitation and shortness of breath occurred one week ago. Blood pressure and blood sugar were measured as low as 68/47 mmHg and 2.4 mmol/L in outpatient department of our hospital. After thorough examination, the diagnosis was made: Adenohypopituitarism, massive pericardial effusion and pituitary crisis were treated with hydrocortisone 300 mg qd, gradually reduced, and levothyroxine sodium tablets were taken orally in small quantities. Meanwhile, anti-infection and symptomatic supportive treatment improved the symptoms. After discharge, it was changed to oral prednisone 10 mg in the morning, 2.5 mg in the afternoon, levothyroxine sodium tablet 50 μg qd. The pericardial effusion disappeared 1 month later. Conclusion: Pericardial effusion is the initial manifestation of adenohypopituitarism, and its clinical manifestations lack specificity and are easy to miss diagnosis. The diagnosis of this case was delayed for at least 2 years. A review of the diagnosis and treatment showed that the main reasons for misdiagnosis were as follows: 1) Clinicians lack understanding of secondary hypothyroidism and hypopituitarism, and fail to complete timely examinations to make a clear diagnosis and guide treatment; 2) Lack of specificity of symptoms; 3) Patient compliance problem: Lack of education for patients, patients failed to return to the doctor on time to trace the cause.