Endocrine Abstracts

Case History: We report a case of 81-year-old female of white background who was admitted after a fall with long lie and confusion. On arrival, she was found to be hypotensive BP-85/46 mmHg, Hypothermic-temp-20.9 and bradycardic HR-46 beats/min, GCS was 13/15 with low normal CBG-4.0 mmol/l. She has a history of chronic hyponatraemia, thyroidectomy 9 years prior to this presentation and a previous admission with fall leading to pelvic fractures. During that admission she was started on 25 mg levothyroxine but she later declined levothyroxine therapy due to her concerns about its side effects.

Investigations: Serum Sodium-122 mmol/litre (low), paired osmolalities- Serum osmolality-255mosm/KgH2O, urine osmolality-291 mosm/KgH2O, urine sodium-89.

Other biochemistry: CPK-2890U/l (25-200)), Random Cortisol-793 nmol/l, TSH>48.10mIU/l (0.30-4.80), Free T4-<3.2pmol/l (7.7-20.6), Hi Sens CRP 99.7mg/l (0.0-5.0) CBG-4.0 mmol/l initially, improved later to 6.4 mmol/l. CXR-unremarkable, Urinalysis- NAD CT Head showed no acute brain injury.

Management: As the available thyroid hormone level was deranged along with her clinical presentation, we suspected myxoedema coma, for which she was treated with intravenous Liothyronine T3-20 mg followed by levothyroxine via a nasogastric tube, starting at a dose of 50 mg and 2.7% hypertonic saline infusion as she had confusion and had altered sensorium. Her sodium level improved from 122 mmol/l to 136 mmol/l over 10 days and her symptoms completely resolved. She was discharged on Levothyroxine 150 mg. She was also treated empirically with antibiotics due to an elevated C-reactive protein.

Conclusion: This is an interesting case as this post-menopausal lady had suffered from falls and chronic hyponatraemia presented with myxoedema crisis precipitated by an unspecified infection and the fact the she had declined thyroid replacement therapy. Her sodium levels improved and symptoms resolved after hormone replacement was initiated. She is being discharged back to the care of her GP with thyroid function test monitoring in 4-6 weeks’ time.