Endocrine Abstracts

Introduction: Myxedematous coma is a rare endocrine emergency that settles in the absence of appropriate treatment for hypothyroidism for a long period. The severe and chronic reduction of serum thyroid hormones culminates in the insufficiency of compensatory mechanisms that maintain the physiological homeostasis of the organism. The clinical condition is severe, commonly associated with hypoxemia, hypercapnia, hypothermia, reduced cardiac output, and altered mental status.

Case report: A 60 years old female patient with a previous history of thyroidectomy, was admitted at the Hospital hemodynamically unstable, with bradycardia, hypothermia, sedated with midazolam 10 mL/hr, and fentanyl 10 mL/hr, RASS scale – 2 (Richmond Agitation Sedation Score), and miotic pupils. Blood pressure 115x80 mmHg with noradrenaline 10 mL/hr, heart rate 52 bpm, and oxygen saturation 94% on mechanical ventilation. Due to high suspicion of myxedematous coma, was administered an attack dose of levothyroxine (500 mg/day) via a nasogastric probe in the first three days with hydrocortisone 100 mg every 8 h. Levothyroxine dose was maintained at 250 mg/day by a nasogastric probe, and hydrocortisone 50 mg intravenous every 8 h. Laboratory: amylase (160 UI/l) and lipase (250 UI/k), TSH 26 (0.3 and 4.0 mU/l) and free T4 <0.017 (0.9 to 1.8 ng/dl). Chest tomography: massive pericardial and pleural effusion, as well as parenchymal opacities in the outstanding portions and septal thickening inferring pulmonary edema. X-ray: increase cardiothoracic ratio caused by pericardial effusion. Abdominal computerized tomography: ascites, more evident in the upper abdominal (peri-hepatic) and liquid infiltration of intra and extraperitoneal fat by generalized anasarca. She was unstable during the hospitalization period, presented with progressive hypoxemia and hemodynamic instability. Thus, due to suspicion of pulmonary thromboembolism, in addition to the adjustment of vasoactive drugs, full dose enoxaparin was initiated. Meantime, due to the severe condition of refractory hypotension the measures instituted, the patient progresses to death on his twenty-second day of hospitalization.

Conclusion: Although myxedematous coma has an arduous prognosis, there are still gaps regarding the best medication management. It emphasizes the need for studies for the development of a scientific basis that standardizes the most appropriate pharmacological treatment to be instituted. Since there is no consensus on the best form of monotherapy - T4 or in combination with T3. Furthermore, there is a lack of data in the literature to corroborate the effective dose of levothyroxine orally in a myxedematous coma in places where there is no IV medication, such as the situation of this clinical case.