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Cimino-Fiallos N, Hurt B. Hypothyroidism-Etiologies, Evaluation, and Emergency Care. Emerg Med Clin North Am 2023; 41:743-758. [PMID: 37758421 DOI: 10.1016/j.emc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Thyroid hormone affects every human organ system and is a vital component of metabolism. Common and easily treatable, hypothyroidism does not usually require emergency management. However, myxedema coma is the decompensated form of hypothyroidism and can be life threatening if not treated expediently.
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Affiliation(s)
- Nicole Cimino-Fiallos
- Meritus Health Emergency Department, 11116 Medical Campus Drive, Hagerstown, MD 21742, USA
| | - Brenten Hurt
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA.
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Chaudhary S, Das L, Sharma N, Sachdeva N, Bhansali A, Dutta P. Utility of myxedema score as a predictor of mortality in myxedema coma. J Endocrinol Invest 2023; 46:59-65. [PMID: 35945394 DOI: 10.1007/s40618-022-01884-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/26/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking. DESIGN AND METHODS All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients. RESULTS A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine. CONCLUSION Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.
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Affiliation(s)
- S Chaudhary
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension Block, 1012, Chandigarh, 160012, India
| | - L Das
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension Block, 1012, Chandigarh, 160012, India
| | - N Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - N Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension Block, 1012, Chandigarh, 160012, India
| | - A Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension Block, 1012, Chandigarh, 160012, India
| | - P Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension Block, 1012, Chandigarh, 160012, India.
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Yoshinaka A, Akatsuka M, Yamamoto S, Yamakage M. Sudden cardiac arrest associated with myxedema coma due to undiagnosed hypothyroidism: a case report. BMC Endocr Disord 2021; 21:229. [PMID: 34789203 PMCID: PMC8596363 DOI: 10.1186/s12902-021-00894-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Myxedema coma, which occurs due to hypothyroidism, is a rare and life-threatening condition. Some patients have hemodynamic dysfunction, which consequently leads to cardiac arrest. The rarity of this condition makes it difficult to determine the cause of cardiac arrest. It is important to diagnose myxedema coma based on clinical findings, including physical examination and laboratory parameters. We present a case of undiagnosed and untreated hypothyroidism that initially caused myxedema coma and then led to cardiac arrest. CASE PRESENTATION A 56-year-old woman who had no medical history was transferred to our hospital for the management of return of spontaneous circulation due to sudden cardiac arrest. Findings of laboratory tests revealed that she had hypothyroidism. On physical examination, she was found to have a puffy face, thin eyebrows, and severe systemic non-pitting edema. Therefore, the patient was clinically diagnosed with myxedema coma, which was the cause of cardiac arrest. She was treated with thyroid hormone and hydrocortisone, resulting in improvement in her general condition, except for the neurological dysfunction. CONCLUSIONS This case suggests that myxedema coma is caused by undiagnosed and untreated hypothyroidism, leading to sudden cardiac arrest. Our findings are useful in the differential diagnosis of hypothyroidism based on characteristic physical examination findings. Clinicians should be aware of the differential diagnosis of myxedema coma based on findings from physical examination and laboratory testing of thyroid function, and the treatment should be started immediately.
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Affiliation(s)
- Asami Yoshinaka
- Department of Anesthesiology, Obihiro Kosei Hospital, West 14, South 10, 080-0024, Obihiro, Hokkaido, Japan
| | - Masayuki Akatsuka
- Department of Anesthesiology, Obihiro Kosei Hospital, West 14, South 10, 080-0024, Obihiro, Hokkaido, Japan.
| | - Shuji Yamamoto
- Department of Anesthesiology, Obihiro Kosei Hospital, West 14, South 10, 080-0024, Obihiro, Hokkaido, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1West 16, Chuo-ku, 060-8543, Sapporo, Hokkaido, Japan
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Rajendran A, Bhavani N, Nair V, Pavithran PV, Menon VU, Kumar H. Oral Levothyroxine is an Effective Option for Myxedema Coma: A Single-Centre Experience. Eur Thyroid J 2021; 10:52-58. [PMID: 33777819 PMCID: PMC7983610 DOI: 10.1159/000507855] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/12/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Myxedema coma is an endocrine emergency with a very high mortality rate. As per the American Thyroid Association, initial thyroid hormone replacement for myxedema coma should be intravenous levothyroxine (LT4). However, in India, the availability of intravenous LT4 is limited. Often, crushed LT4 tablets are given through the enteral route when parenteral therapy is unavailable. No data or protocol is available for the administration of oral LT4 in myxedema coma. The aim of this study was to assess the effectiveness of oral LT4 in patients diagnosed with myxedema coma and to formulate a protocol for oral LT4 that can be used to guide the treatment of patients when intravenous LT4 is unavailable. METHODS This retrospective observational study included patients diagnosed with myxedema coma between January 2010 and December 2019. The diagnosis of myxedema coma was based on the diagnostic scoring system for myxedema coma proposed by Popoveniuc et al. [Endocr Pract. 2014 Aug;20(8):808-17]. Dosing of oral LT4 was decided as per our institutional protocol. RESULTS Fourteen patients (11 males and 3 females) with a median age of 67.5 years (range 11-82) with myxedema coma were included. All patients had central nervous system manifestations, and sepsis was the most common precipitating factor. The median myxedema score was 72.5 (normal ≤25), and the median length of hospital stay was 12 days (range 3-18). The oral LT4 regimen consisted of a loading dose of 300-500 μg, followed by taper over the next 3-5 days. With this regimen, 13 patients survived, and only 1 patient died. CONCLUSION Oral LT4 is an effective treatment option for myxedema coma when intravenous LT4 is unavailable.
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Affiliation(s)
| | - Nisha Bhavani
- *Nisha Bhavani, Department of Endocrinology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Aims Ponekkara PO, Cochin, Kerala 682041 (India),
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Izumi K, Ono Y. [A case of elderly myxedema coma patient with end-stage renal failure]. Nihon Ronen Igakkai Zasshi 2021; 58:152-157. [PMID: 33627552 DOI: 10.3143/geriatrics.58.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
CASE 84-year-old woman had been diagnosed hypothyroidism before, but she did not take tablets of thyroid hormone prescribed. Anorexia and decreased consciousness level were discovered by workers of the facility. Her family doctor found thyroid function abnormality as a cause, and she was introduced to our hospital to treat because the whole body condition was bad. Her physical examination was observed that JCS was 3-10. Laboratory examination showed that TSH 562.81 μIU/mL, fT4 0.40 ng/mL, pH 7.33, and Na 124 mEq/L. It was not a contradictory finding with the diagnostic criteria of mucus edema coma. Blood and peritoneal dialysis is denied, although her data indicated eGFR 8-10 ml/min/1.73 m2. Her hospitalization was long-term, but exhibited finally good clinical course. After three months of hospitalization, she was discharged from the hospital. The problems were as follows. The clear guideline of myxedema coma with end-stage renal failure state and many complications was not found. She and her family did not hope dialysis under this condition.We treated a case of myxedema coma in a case of an elderly person with terminal renal failure who did not hope dialysis. In addition to myxedema coma as a rare disease, there are many basic diseases in the elderly. Although it was a difficult case, it is important to repeatedly confirm the explanation and the intention of the person and the family with regard to the selection of the treatment policy.
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Affiliation(s)
- Kenichi Izumi
- Department of Preventive Medicine and Internal Medicine, Takagi Hospital.,Department of Endocrinology & Metabolism, Takagi Hospital
| | - Yasuhiro Ono
- Department of Endocrinology & Metabolism, Takagi Hospital
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Verma V, Menon AS, Bahadur A, Sikarwar A. Clinical manifestation and images of a patient having cardiovascular involvement in myxoedema coma. Med J Armed Forces India 2021; 77:92-95. [PMID: 33487873 DOI: 10.1016/j.mjafi.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 12/03/2018] [Indexed: 11/17/2022] Open
Abstract
Myxoedema coma is an endocrine emergency characterised by diminished sensorium associated with features of severe hypothyroidism. The disease carries a high mortality of 30%-60 %. The cardiac manifestation of the disease consists of bradycardia, hypotension, pericardial effusion and certain echocardiographic changes such as heart block and features of hypothermia. Here, we report a case of myxoedema coma with characteristic cardiac manifestations. These manifestations revert promptly on starting treatment, and achieving a eumetabolic status as was demonstrated in this patient.
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Affiliation(s)
- Vishesh Verma
- Classified Specialist (Medicine) and Endocrinologist, Command Hospital (Central Command), Lucknow Cantt, India
| | - Anil S Menon
- Commandant, Military Hospital Mhow, Madhya Pradesh, India
| | - Ajay Bahadur
- Senior Advisor (Medicine) and Endocrinologist, Command Hospital (Central Command), Lucknow Cantt, India
| | - Ajeet Sikarwar
- Junior Resident (Medicine), Command Hospital (Central Command), Lucknow Cantt, India
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Bridwell RE, Willis GC, Gottlieb M, Koyfman A, Long B. Decompensated hypothyroidism: A review for the emergency clinician. Am J Emerg Med 2020; 39:207-212. [PMID: 33039222 DOI: 10.1016/j.ajem.2020.09.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Decompensated hypothyroidism, formerly known as myxedema coma, is an endocrine emergency that commonly presents with altered mental status, as well as hypothermia and depressed vital signs. The condition is often caused by an inciting event, which may lead to significant delays in the diagnosis and management of this disease. Although the incidence is low, this disease is associated with significant morbidity and mortality. Therefore, it is important for emergency clinicians to be aware of this condition. OBJECTIVE This narrative review evaluates the emergency medicine diagnosis and management of adult patients with decompensated hypothyroidism. DISCUSSION Decompensated hypothyroidism is a severe hypothyroid state associated with multiple organ failure. The diagnosis can be challenging due to similarities with more common diseases and lack of consideration of the diagnosis. Many patients may present with altered sensorium or depressed vital signs. Clinicians should obtain a thyroid stimulating hormone and free thyroxine level when considering the diagnosis. Management involves resuscitation, early steroid supplementation, thyroid hormone replacement, and treatment of the inciting event. CONCLUSIONS Decompensated hypothyroidism should be considered in the evaluation of patients with altered sensorium and depressed vital signs so as to not miss this critical diagnosis.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency, Medicine Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - George C Willis
- Department of Emergency, Medicine University of Maryland School of Medicine, 110 S. Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, United States.
| | - Michael Gottlieb
- Department of Emergency, Medicine Rush University Medical Center, Chicago, IL 60612, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX, 75390, United States
| | - Brit Long
- Department of Emergency, Medicine Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
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Abstract
Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient morbidity and mortality. The most common critical endocrine abnormalities are associated with functional tumors, such as pheochromocytomas, insulinomas, and carcinoid tumors, leading to carcinoid syndrome, abnormal thyroid function, or disturbances in the hypothalamus-pituitary-adrenal axis, causing adrenal insufficiency. This article aims to discuss the pathophysiology, diagnosis, and perioperative management of pheochromocytomas, hyperthyroidism, hypothyroidism, adrenal insufficiency, carcinoid disease, and insulinomas.
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Affiliation(s)
- Dasun Peramunage
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101, USA
| | - Sara Nikravan
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101, USA; Division of Critical Care Medicine, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101, USA.
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Villalba NL, Zulfiqar AA, Saint-Mezard V, Ortiz MBA, Kechida M, Zamorano NF, Ortega SS. Myxedema coma: four patients diagnosed at the Internal Medicine Department of the Dr. Negrin University Hospital in Spain. Pan Afr Med J 2019; 34:7. [PMID: 31762876 PMCID: PMC6850735 DOI: 10.11604/pamj.2019.34.7.19164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/26/2019] [Indexed: 11/17/2022] Open
Abstract
Myxedema coma is a rare complication of hypothyroidism. Clinical examination may reveal hypotension, bradycardia, and hypothermia. Laboratory tests may show hyponatremia, lipid disorders, and elevations of creatine kinase, liver, and cardiac enzymes. We describe four cases diagnosed in our hospital during the period 1999-2017. The patients were related to amiodarone treatment, noncompliance with hormone replacement therapy, or a new diagnosis of hypothyroidism. Intravenous hormone replacement therapy was effective in three of the cases and one died. The outcome of this disease may be fatal as seen in one of our cases.
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Affiliation(s)
- Noel Lorenzo Villalba
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Abrar-Ahmad Zulfiqar
- Service de Médecine Interne, Diabète et Maladies Métaboliques, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Melek Kechida
- Service de Médecine Interne et Diabète, Hôpital Universitaire Fatouma Bourguiba, Tunisia
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Heksch RA, Henry RK. Myxedema Coma due to Hashimoto Thyroiditis: A Rare but Real Presentation of Failure to Thrive in Infancy. Horm Res Paediatr 2019; 90:332-336. [PMID: 29730659 DOI: 10.1159/000488467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/11/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hashimoto thyroiditis (HT) is uncommon in infancy, and myxedema coma (MC) is even less common. While prior reports have documented these entities separately, to our knowledge, MC in combination with HT has not been reported before in this age group. METHODS/RESULTS A 10-month-old female presented with ptosis, lethargy, dysphagia, and failure to thrive (FTT). She developed hypotension, bradycardia, hypothermia, and apnea requiring intubation. Initial thyroid-stimulating hormone was 422 μIU/mL, and free thyroxine was < 0.5 ng/dL, despite the presence of a normal thyroid newborn screen (NBS). Of note, sepsis workup was unremarkable. With the diagnosis of MC, treatment with intravenous levothyroxine was initiated, although after hydrocortisone administration to avert the possibility of an adrenal crisis, despite a random cortisol of 16.4 μg/dL. Based on positive thyroid antibodies suggesting HT, autoimmune workup later revealed positive acetylcholinesterase antibodies consistent with a diagnosis of ocular myasthenia gravis. CONCLUSION MC may be a cause of altered mental status in infancy and may simultaneously be associated with FTT on presentation. With the presence of a normal thyroid NBS, autoimmunity should be entertained as the etiology of profound hypothyroidism, as positive thyroid antibodies may prompt an exploration for coexisting diseases which may explain other presenting features.
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Abstract
Myxedema coma is a rare endocrine emergency resulting from the decompensation of severe hypothyroidism, which is associated with a high mortality rate. It is characterized by the deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation. Early disease diagnosis and advancements in intensive supportive care have reduced the mortality rate. Besides intensive supportive care, appropriate management of the underlying thyroid hormone deficiency is essential. However, as the disease is rare and unrecognized, evidence-based treatment of myxedema has not yet been established in many countries. An 84-year-old Japanese man with a history of Hashimoto's thyroiditis was referred to our hospital. On arrival, conscious disturbance, hypothermia, hypotension, and hypoventilation were observed. He had discontinued thyroid hormone replacement therapy for a year. He was diagnosed with myxedema coma. Immediately, he received intensive supportive care and a combination therapy of 200 μg levothyroxine and 50 μg liothyronine until the fifth hospital day. Subsequently, monotherapy with levothyroxine was continued at a dose of 150 μg daily. The thyroid hormone level reached the normal range a few days later, and cardiovascular disease did not develop during hospitalization. This case demonstrated the efficacy of the combination of levothyroxine and liothyronine in treating myxedema coma.
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Affiliation(s)
- Kazuhiro Ueda
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Atsushi Kiyota
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Mariko Tsuchida
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Mikako Okazaki
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
| | - Nobuaki Ozaki
- Division of Endocrinology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya 453-8511, Japan
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Abstract
BACKGROUND Myxedema coma is profound decompensated hypothyroidism usually precipitated by stressors, and its occurrence in association with total thyroidectomy or metabolic disorders, such as diabetic ketoacidosis, is unusual. CASE PRESENTATION A 43-year-old Asian man with history of total thyroidectomy who was scheduled for a second radioactive iodine therapy presented to our hospital with decreased mental status and hyperglycemia. He had a history of thyroid cancer but did not have diabetes mellitus. He was in a hypothermic state and had a Glasgow Coma Scale score of 10 out of 15 at presentation; arterial blood gas analysis revealed a state of metabolic acidosis and laboratory findings suggested hyperglycemia with glycosuria, ketoacidosis, and severe hypothyroidism. A thyroid function test showed thyroid-stimulating hormone of 34.126 uIU/mL, free thyroxine of 1.02 ng/dL, and triiodothyronine of 1.04 ng/mL. The glycated hemoglobin of this patient was checked due to hyperglycemia and the value of glycated hemoglobin was 16.5% which met the criteria for a diagnosis of diabetes. After treatment for myxedema with liothyronine 5 mcg two times per day and levothyroxine 175 mcg once daily via a nasogastric tube and diabetic ketoacidosis with intravenously administered fluid and insulin, his clinical condition rapidly improved including mental status, hyperglycemia, and acidosis. During the hospitalization, a workup for diabetes mellitus was performed and the results suggested that a diagnosis of type 2 diabetes mellitus would be appropriate. CONCLUSIONS This case demonstrated that diabetic ketoacidosis not only could be a potential contributor to myxedema coma but also mask typical clinical features, making diagnosis more difficult. Considering the possibility of an increasing number of potential patients with hypothyroidism developed after thyroidectomy, constant vigilance is required for a better clinical outcome, including early recognition and management in critical care in advance for unusual diabetic ketoacidosis which could precipitate decompensated hypothyroidism.
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Affiliation(s)
- Jin Joo Kim
- Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul, 137-701, Korea
| | - Eun Young Kim
- Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul, 137-701, Korea.
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Yafit D, Carmel-Neiderman NN, Levy N, Abergel A, Niv A, Yanko-Arzi R, Zaretski A, Wengier A, Fliss DM, Horowitz G. Postoperative myxedema coma in patients undergoing major surgery: Case series. Auris Nasus Larynx 2018; 46:605-608. [PMID: 30454972 DOI: 10.1016/j.anl.2018.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 10/22/2018] [Accepted: 10/30/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Myxedema coma is a serious complication of hypothyroidism that can be precipitated by major surgery. It is extremely rare, with only a few reports in the literature. This study aims to present a relatively large case series of post-surgical myxedema coma and to analyze medical and surgical risk factors. METHODS Analysis of the patients' surgical records and medical charts. RESULTS Four patients developed postoperative myxedema coma and were evaluated for risk factors. Three had known hypothyroidism. Two had undergone large head and neck composite resections necessitating a free flap repair for malignant disease. One had undergone coronary artery bypass graft for ischemic heart disease, and another had undergone endoscopic cholecystectomy for complicated cholecystitis. All four patients required prolonged hospitalization, including treatment in the intensive care unit. One patient had undergone full cardiopulmonary resuscitation directly related to the myxedema coma state. CONCLUSION We present a series of four patients who developed myxedema coma following major surgery. We recommend that patients with known hypothyroidism who are scheduled for major surgery should be tested for thyroid function status and assessed for postoperative risk of hypothyroidism. Those who develop complications following major surgery, should be immediately tested for thyroid function to rule out myxedema coma.
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Affiliation(s)
- Daniel Yafit
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Narin Nard Carmel-Neiderman
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Levy
- Department of Anesthesiology, Pain and Critical Care, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avrham Abergel
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Niv
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ravit Yanko-Arzi
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arik Zaretski
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Wengier
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Horowitz
- Department of Otolaryngology, Head & Neck and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Affiliation(s)
- A Garrahy
- Department of Endocrinology, Beaumont Hospital, Beaumont, Dublin 9, Ireland.
| | - A Agha
- Department of Endocrinology, Beaumont Hospital and RCSI Medical School, Beaumont, Dublin 9, Ireland.
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Thompson MD, Henry RK. Myxedema Coma Secondary to Central Hypothyroidism: A Rare but Real Cause of Altered Mental Status in Pediatrics. Horm Res Paediatr 2018; 87:350-353. [PMID: 27631398 DOI: 10.1159/000449223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/17/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Myxedema coma (MC), a medical emergency defined as severe hypothyroidism leading to altered mental status, is more common in older women with hypothyroidism. METHODS/RESULTS A 7-year-old Caucasian male with chromosome 1q deletion presented with altered mental status preceded by milestone regression. His presenting labs results were: thyroid-stimulating hormone (TSH) 0.501 μIU/ml and free thyroxine (T4) <0.5 ng/dl. His morning cortisol level was 8.1 μg/dl with repeat testing, while TSH was 1.119 μIU/ml and free T4 was 0.5 ng/dl. Low-dose cosyntropin test showed baseline and peak cortisol levels of 1.9 and 16 μg/dl, respectively. Aside from altered mental status, heart block was present in addition to hypothermia and hypercarbia. Diffuse cerebral cortical and corpus callosum atrophy were seen on MRI. An intravenous (i.v.) stress dose of hydrocortisone was administered for 24 h prior to an i.v. loading dose of levothyroxine. His activity level subsequently returned to baseline within 48 h after treatment had been initiated. CONCLUSION Though MC is rare, occurring mainly with noncompliance in primary hypothyroidism, it may occur at the diagnosis of secondary hypothyroidism. Based on features like hypothermia, hypoventilation, and cardiovascular instability occurring in the setting of central hypothyroidism, it should be suspected and managed urgently in order to avert the associated high mortality resulting from treatment delays.
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Affiliation(s)
- Michael D Thompson
- Section of Endocrinology, Metabolism and Diabetes, Nationwide Children's Hospital, Columbus, Ohio, USA
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Komiya A, Watanabe A, Kawauchi Y, Takano A, Fuse H. Severe oligozoospermia in a patient with myxedema coma. Reprod Med Biol 2012; 11:207-11. [PMID: 29699124 DOI: 10.1007/s12522-012-0129-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 04/16/2012] [Indexed: 10/28/2022] Open
Abstract
A case of severe oligozoospermia with myxedema coma is herein presented. The patient was referred to a male infertility clinic with a 5-year history of primary infertility. Decreased serum testosterone and elevated serum prolactin without abnormal MRI findings in the hypothalamus, and decreased semen volume and sperm motility were noted. A GnRH test revealed a decreased luteinizing hormone response, whereas the HCG test showed a normal testosterone increase. Because a urinalysis after ejaculation indicated retrograde ejaculation, imipramine administration was started. However, the semen quality deteriorated, so the patient was referred to an ART clinic. Twenty-one months from the initial visit, the patient developed a loss of consciousness and edema due to myxedema coma, a life-threatening state of hypothyroidism. The patient recovered after 1 month of thyroid hormone replacement therapy (HRT) with corticosteroids. Three months after the myxedema coma, a semen analysis showed a decreased semen volume (0.2 mL) and severe oligozoospermia (two spermatozoa/ejaculate). Elevated prolactin and decreased testosterone levels were still present. These parameters gradually improved after restoration of euthyroidism by HRT. In conclusion, physicians should confirm the thyroid function in the management of male infertility, especially in patients with elevated prolactin levels.
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