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Understanding Myxedema Coma

February 18, 2020

A 71 year old males arrives by EMS for altered mental status that began this morning. He resides at an assisted living, where he recently moved three months ago from South Carolina.

 

His prior medical history is significant for osteoarthritis, hypertension, HFREF (45% EF) secondary to CAD s/p stent two years ago. His medication list includes nicardipine, metoprolol, statins, and aspirin.

 

Vitals: 88/60, HR: 72, T: 35.1, RR: 12

Initial fingerstick: 55

 

Physical Exam:

  • General: Overweight male resting on stretcher; responds yes intermittently to questions; does not follow commands

  • Head:  Atraumatic, edematous face,

  • Skin: No rashes, no trauma, 2+ pitting edema ankles and hands

  • Eyes: Spontaneously opens, responds to sternal rub, reflexes 2+

  • CVS: S1, S2, 1+ bilateral pitting edema ankles, hands

  • Pulm: decreased breath sounds at bilateral bases

  • GI: obese abdomen; soft, non-tender, non-distended

  • Neuro: PERRL, symmetric responsive 3mm pupils

 

RUSH exam:

  • No B lines, b/l lung sliding

  • Trace pericardial fluid, no tamponade physiology

  • IVC collapsible,

  • Fluid anterior & posterior to desc. Aorta,

  • No free fluid Morrison’s, Splenorenal, Bladder

 

Rest of workup:  

  • Na 128

  • Other electrolytes, CBC, & UA - within normal limits

  • Salicylate/APAP/Utox negative

  • ABG - 7.38/46/94

  • TSH/T4: 34/ 0.31,

  • Random cortisol/CPK - within normal limits

  • BNP, trop, EKG  - within normal limits

  • ECHO 45% with no regional wall motion abnormality

  • CXR: bilateral pleural effusions

  • CT head negative

  •  Blood Culture x2 neg, Urine Culture neg (obtained after admission)

 

Interventions:

  • D50 amp

  • 500 ccs lactated ringers

  • IV hydrocortisone

  • levothyroxine

  • norepinephrine gtt

 

Further history: Outside medication list reveals that the patient was prescribed levothyroxine, but was never re-prescribed dose when moved,

 

Admitted to MICU, patient regained mental status gradually, weaned off NE, and ultimately discharged.

 

Take Away #1:

  • Keep differential for AMS broad: ‘PIE TENT’

  • Psychiatric, Infectious, Endocrine, Toxicology, Electrolytes, Neuro, Trauma

 

Take Away #2:

Myxedema Coma/Decompensated hypothyroidism - usually the hypothyroidism is  known, but patients just don’t have access or don’t receive their medications.

 

50% of cases become evident after admission.

 

Mortality 30-50%; If untreated, mortality approaches 100%.

 

Diagnosis is suggested by:

  • AMS – usually not in coma

  • Presence of hypothermia OR bradycardia

  • PE findings: loss of lateral 1/3 eyebrow, non-pitting edema

  • Check TSH, Free T4, random serum cortisol.

  • If known hypothyroidism and maxed out pressors: consider T4 as may increase MAP/decrease vasopressor requirement

 

Treatment:

  • Levothyroxine 200-400 mcg IV Push,

  • Hydrocortisone 100mg IV (empiric treat adrenal crisis,

  • send random cortisol before giving hydrocortisone)

  • T3 (controversial)  5-20 mcg IV; can precipitate arrhythmias

 

Take Away #3:

  • Identify Trigger, r/o adrenal crisis , monitor complications

  • Most common cause: Thyroid supplementation nonadherence – check external medication history

 

Precipitants include:

  • Medications – beta blockers, antipsychotics, diuretics

  • Infection – CXR, BC, UA, LP

  • MI or HF exacerbation

 

Monitor complications:

  • Hypoglycemia, Hyponatremia, Respiratory support (macroglossia), cardiovascular support (tamponade, low BP),

  • Adrenal insufficiency (stress dose steroids)

James Tavornwattana, MD is a current first year resident at Stony Brook Emergency Medicine.

 

References:

 

Edited by Bassam Zahid, MD

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