Myxoedema coma secondary to severe hypothyroidis

Abstract

Introduction: Myxoedema is a medical emergency associated with a highmortality rate. It is a rare presentation of severe hypothyroidism andsalient features usually seen include Decreased Mental Status,Hypothermia. Other features like Bradycardia, hypotension, hypoglycaemia,hypoventilation, signs of cognitive impairment like confusion, agitation,disorientation, and even psychotic features could be seen.Precipitants like alcohol, sedative drugs, MI, sepsis, exposure to cold mayalso result in severe hypothyroidism; hence effort should be made toreverse precipitating factors rapidly.The incidence of Myxoedema Coma is very low in developed countriesas there is improved diagnosis and treatment; early, aggressive treatmentis necessary due to the high mortality rate (30–60%). Groups of patientsat risk include elderly patients, those with a compromise cardiovascularsystem, reduced consciousness, sepsis etc. usually have a poorer outcome.Mainstay of treatment is thyroid hormone therapy, supportive-reversalof precipitating factors. Adrenal insufficiency should be excluded; glucocorticoidsare given to the patient.Case report-discussion & results: I present an 89-year-old woman who presentedwith Back Pain, Confusion following opioid medications prescribedby the GP. However on admission, there was hypothermia,hypotension with cold peripheries, pedal discolouration and ulceration,pitting oedema. The patient was initially managed for pneumonia, acutekidney injury secondary to poor intake. Patient was rehydrated andplaced on antibiotics. ECG, Transthoracic Echocardiography, ChestX-Ray, Blood tests, Brain CT showed nil tumour or acute changes. CTTAP showed nil malignancy or bony changes.Few days following admission to the ward, patient tested positivefor COVID and was isolated. Following COVID Stepdown, the patientdeveloped altered sensorium, hypotension, and seizures. Lactate washigh, EEG showed nil evidence of encephalitis. A confusion screen whichincluded Thyroid Function Test (TFT) was requested. The lab called ina few hours later due to a very high level of TSH (63) and low T4 (5.1)and Levothyroxine was commenced. Referral was made to the endocrinologist.Gentle rewarming using blankets with the room heater at roomtemperature was done and the patient was also placed on antibiotics.Relatives were updated as events evolved, and diagnosis changed withtime. Repeat TFT showed that the TSH level increased and there was clinicalworsening of the patient’s mental state. A diagnosis of Myxoedemacoma was made.Conclusion: A low threshold for requesting investigations like TFT, especiallyin at-risk patients and a high index of suspicion is required clinically.Could Covid have contributed to the precipitating factors? Areferral was made to the Palliative Care Team. There was good multidisciplinaryteam input with relatives updated from time to time with mentionof limited prognosis.