Endocrine Abstracts

Introduction: Myxoedema coma is a rare complication of hypothyroidism. Although malnutrition is considered rare in developed countries, research has indicated that there are more than three million people in the UK suffering from or at risk of malnutrition. We present a case of myxoedema coma co-existing with malnutrition.

Case report: A 51-year-old Caucasian female presented with acute confusion, peripheral oedema and a bilateral lower limb rash. On examination she exhibited proximal muscle weakness, slow relaxing reflexes and an erythematous macular rash on her lower legs. She had a family history of hypothyroidism. Investigations revealed severe hypothyroidism (TSH >100 mU/l and T₄ 6.6 pmol/l), a normocytic anaemia (Hb 9.1 g/dl) and hyponatraemia (Na 114 mmol/l). A Short Synacthen test was performed with an adequate response and both a coeliac screen and vitamin B12 levels were normal. An ultrasound scan of the thyroid revealed features consistent with Hashimoto’s thyroiditis and thyroid peroxidase antibody was positive. She was treated with levothyroxine 100 μg once daily. Punch biopsies of the skin rash were suggestive of zinc deficiency. Further investigations revealed deficiencies in magnesium and vitamin D as well as hypoalbuminaemia (27 g/l). She had a BMI of 15. In view of these findings, a diagnosis of malnutrition was reached. The patient was treated with vitamin D, zinc and dietary supplements to good effect. Her sodium normalised, her confusion resolved and her muscle weakness improved.

Discussion: Primary hypothyroidism presenting with myxoedema coma is an important differential diagnosis in all patients presenting with acute confusion. Timely diagnosis can be life-saving. This case highlights the importance of realising that not all patients with hypothyroidism will exhibit classical features such as weight gain.