Endocrine Abstracts

Introduction and Backgrounds: Myxedema coma is a severe life threatening form of decompensated hypothyroidism which is associated with a high mortality rate. Infections and discontinuation of thyroid supplements are the major precipitating factors. It’s characterized by a decreased mental status, hypothermia, bradycardia, hypotension, and hypoventilation. Very few cases of Myxedema coma have been reported till date, actual prevalence is unclear with the estimated incidence rate of 0.22 cases per million people per year. The purpose of the present article is to describe a fatal case of myxedema coma in an elderly woman occurring in the context of immunodeficiency.

Case Presentation: A 61-year-old woman with a past medical history of hypertension, type 2 diabetes, end-stage renal failure, miliary tuberculosis with pulmonary and peritoneal involvement under anti-bacillary treatment, autoimmune thyroiditis with discontinuation of L-thyroxine since 2 months. She was admitted to the emergency department for altered mental status. At admission her vital signs revealed a blood pressure of 20/70 mmHg, bradycardia at 54 bpm, hypothermia at 35 °C. The patient presented with dry depilated skin, vitiligo and generalized myxedema, the Glasgow Coma Scale was 10/15. The patient was transferred to the intensive care unit. The initial laboratory evaluation revealed the normochromic normocytic anemia and absence of electrolyte disturbances, Thyroid function was altered with thyroidstimulating hormone (TSH) of 100 mU/l and free thyroxin (T4) of 3.9 pmol/dl and free (T3) of 1.6 pmol/l. Diagnosis of myxedema coma was made and medical treatment was started. The patient was warmed gradually and oxygen was supplied via a mask. levothyroxin 300 μg was given via a nasogastric tube on third day after admission. The patient’s clinical condition has not improved and she died 3 days later.

Discussion: Myxedema coma is an extreme manifestation in patients with untreated hypothyroidism. The diagnosis could be delayed because diagnostic laboratory data may not be available in a timely manner during emergency presentation. Our patient was also reported to have delayed diagnostic despite she was presented with all-common features of Myxedema coma, because she has other medical history as miliary tuberculosis and end-stage renal failure that make the first diagnostic suspected of a decreased mental status secondary to hyper uremia or central nervous system tuberculosis.

Conclusion: Myxedema coma is a lethal endocrine emergency. Thyroid hormone measurement allows the diagnosis. Protocols with rapid intravenous administration of high doses of thyroid hormones, together with warming and mechanical ventilation, may improve the prognosis.