HYPOTHYROIDISM GONE AWRY: A CASE OF MYXEDEMA COMA

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myxedema coma (MC) is a severe form of hypothyroidism and considered a medical emergency. It is characterized by decreased mentation, bradycardia, depressed respiratory status, hypotension, and general slowing of bodily systems. This a rare condition usually induced by stressors such as infection or malignancy. Here we present a patient undergoing treatment for metastatic carcinoma with incidental diagnosis of this aggressive endocrinological emergency. CASE PRESENTATION: 45-year-old Chinese gentleman with a 2-year history of metastatic esophageal cancer who presented unresponsive. He was undergoing palliative treatment, residing in a nursing home. On admission he required intubation and was found to have mets to his brain which can induce seizures, and was thought to be the cause of his unresponsiveness. He was hypotensive, hyponatremic, minimally responsive, with a lower respiratory rate on arrival. These features fit hypothyroidism. He was started on Dexamethasone for possible vasogenic edema from the brain mets. Lab work discovered TSH to be 162.4 with a FT4 of 0.27. Labs also discovered evidence of adrenal insufficiency with AM cortisol being low despite two days of high dose steroids. He received IV levothyroxine and Stress dose Hydrocortisone. DISCUSSION: : Our patient may have had many precipitating factors of his MC. He had a history of undergoing chemo-radiation before transitioning to palliative care in light of his aggressive cancer. He was receiving PEG tube feeds for over a year which may have impaired metabolism of his levothyroxine. He also continued to lose weight due to his malignancy, without proper readjustment in his weight-based medications. His chronic malnourished state may have contributed to refractory hypothyroidism precipitating MC. CONCLUSIONS: The mortality rates for myxedema coma can range between 30-50% based on different studies. In patients who are terminal, such as our patient with metastatic carcinoma, it is still prudent to keep in mind a simple chronic underlying condition such as hypothyroidism should not go unchecked. Fatal consequences may ensue if thyroid levels are not routinely checked in such individuals. REFERENCE #1: Acharya, R., Cheng, C., Bourgeois, M., Masoud, J., & McCray, E. (2020, September 16). Myxedema Coma: A forgotten medical emergency with a PRECIPITOUS ONSET. Retrieved February 10, 2021, from https://www.cureus.com/articles/41411-myxedema-coma-a-forgotten-medical-emergency-with-a-precipitous-onset REFERENCE #2: Aksoy, N., & Odabasi, G. (n.d.). 23 - case REPORT: Myxedema coma as a complication of cancer treatments. Retrieved February 10, 2021, from https://www.morressier.com/article/23--case-report-myxedema-coma-complication-cancer-treatments/5cdbe0a6618793e647b11e09 REFERENCE #3: Gummalla, S., Manjunath, M., & Phillips, B. (2020, October 22). Myxedema Coma: A life-threatening condition in patients USING PEMBROLIZUMAB. Retrieved February 10, 2021, from https://www.hindawi.com/journals/crie/2020/8855943/ DISCLOSURES: No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Zain Kulairi, source=Web Response No relevant relationships by Sourabh Sourabh, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response