Endocrine Abstracts

Myxoedema coma or severe decompensated hypothyroidism is rare but has high mortality; appropriate early recognition and treatment is essential. We present a case of severe hypothyroidism with multi organ failure. A 58-year-old lady with several months’ history of loss of appetite, tiredness and hair loss presented with progressive lethargy, sleepiness and abdominal distension for 1 week. On admission she was very drowsy, had a doughy dry skin and facial puffiness. Large ascites was present. Vital signs were stable. CXR showed left pleural effusion. Her initial biochemistry showed hyponatraemia, hypokalaemia, acute kidney injury (Cr: 2.03 μmol/l), abnormal LFTs (ALT 2898 IU/l, bilirubin 50 μmol/l), early disseminated intravascular coagulation picture and type 2 respiratory failure (pH: 7.09, pCO2 12) Full liver screens including paracetamol level were negative. Supportive treatments including BiPAP were commenced. Subsequently her TSH was 63 mU/l with undetectable FT₄. She was commenced on levothyroxine 25 μg daily along with intravenous hydrocortisone. She remained on BiPAP without improvement for 4 days. Liothyronine 10 μg tds was added, levothyroxine dose increased to 75 μg od and she improved significantly over the next 2 days. She was off BiPAP, AKI resolved and LFTs improved significantly. USG confirmed significant ascites without evidence of cirrhosis or portal vein thrombosis. Diagnostic tap confirmed this to be a transudate with no growth or malignant cells. Echocardiogram was normal. Gradually her LFTs normalised. Her synacthen test was normal and the hydrocortisone was stopped. 6 weeks later there was complete resolution of ascites, pleural effusion and skin has normalised.

Discussion: Hypothyroidism needs to be considered in anyone with unexplained type 2 respiratory failure. Optimal replacement of thyroid hormone in this condition remains under debate.