Endocrine Abstracts

Profound hypothyroidism leading to coma has not been reported in adolescents.

Case presentation: A 13-year-old adolescent girl presented with coma. Mother reported fatigue, increased sleepiness, deterioration of school performance, apathy, secondary amenorrhea, change in voice, and weight gain for 5 months. No history of dyspnea, palpitations or chest pain, drug intake, trauma, or any systemic illness. No family history of endocrine disorders was reported. Mother reported that the girl lost consciousness after 30 min of feeling dizzy. She had hypothermia (36 C), hypotension (BP=90/55 mmHg), and bradycardia (50/min). She was comatosed (GCS=8/15) with periorbital edema, loss of the lateral eyebrows, dry skin, and large smooth symmetrical firm (40 g) goiter. Her TSH=417 mU/l and FT₄ of 1.7 pmol/l (normal 11–19 pmol/l) and antimicosomal antibody (AMA) titer of 1:1800 confirmed the presence of severe hypothyroidism due to autoimmune thyroiditis. Thyroid ultrasonography revealed bilaterally enlarged thyroid lobes with heterogenous echopattern and multiple nodules. MRI of the sella turcica revealed global diffuse enlargement of the pituitary. She received intravenous T₃ therapy that regained her consciousness in 10 h, followed by intake of L-thyroxine 100 μg daily. Vigor returned and voice improved within 2 weeks. FT₄ and TSH were normalized in 4 weeks. Pituitary size was normalized in the follow up MRI after 6 months.

Discussion: In this case presentation of hypothyroid coma is preceded by lethargy, depression, weakness, forgetfulness, cold intolerance and menstrual disturbance of insidious onset that was overlooked for 5 months. The presence of goiter, periorbital and facial edema and absence of lateral eyebrows were prominent. Aggressive therapy with intravenous thyroxine and external warming lead to excellent prognosis.

Conclusion: This case raises the awareness of physicians to include hypothyroid in the differential diagnosis of coma in this age group.