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Chen DH, Hurtado CR, Chang P, Zakher M, Angell TE. Clinical Features and Outcomes of Myxedema Coma in Patients Hospitalized for Hypothyroidism: Analysis of the United States National Inpatient Sample. Thyroid 2024; 34:419-428. [PMID: 38279788 DOI: 10.1089/thy.2023.0559] [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] [Indexed: 01/29/2024]
Abstract
Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.
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Affiliation(s)
- Dennis H Chen
- Department of Internal Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolina R Hurtado
- Division of Endocrinology, Diabetes and Metabolism, Los Angeles General Medicine Center, Los Angeles, California, USA
| | - Patrick Chang
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Mariam Zakher
- Division of Endocrinology and Diabetes; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Trevor E Angell
- Division of Endocrinology and Diabetes; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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2
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Walsh HL, Shoji MK, Gallo RA, Mervis JS, Maeng MM, Elgart GW, Kirsner RS, Wester ST. Upregulation of Insulin-like Growth Factor-1 Receptor Expression in Pretibial Myxedema: Evidence for a Treatment Target. Am J Dermatopathol 2024; 46:153-154. [PMID: 38055967 DOI: 10.1097/dad.0000000000002597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Affiliation(s)
- Hannah L Walsh
- University of Miami Miller School of Medicine, Miami, FL
| | - Marissa K Shoji
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ryan A Gallo
- University of Miami Miller School of Medicine, Miami, FL
| | - Joshua S Mervis
- Dr Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL; and
| | - Michelle M Maeng
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT
| | - George W Elgart
- Dr Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL; and
| | - Robert S Kirsner
- Dr Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL; and
| | - Sara T Wester
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
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3
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Achonu CU, Olopade OB, Yusuf BO, Fadeyi AA, Fasanmade OA. Case Report of Graves' Disease in a 45-Year-Old Woman Secondary to Herceptin Treatment for Breast Cancer. Monoclon Antib Immunodiagn Immunother 2023; 42:194-202. [PMID: 38156888 DOI: 10.1089/mab.2023.0011] [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] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Graves' disease is the most common cause of thyrotoxicosis and is characterized by ophthalmopathy with proptosis, chemosis, or conjunctival injection; pretibial myxedema; and thyroid acropachy. It is an autoimmune disease that can be genetic or influenced by coexisting environmental factors such as exposure to anticancer drugs, including immune checkpoint inhibitors. The incidence rate of breast cancer is increasing due to rising awareness of risk factors and screening for breast cancer, and the mortality rate is decreasing due to recent advances in cancer treatment. However, there are side effects that are attributed to these treatment modalities, manifesting in various forms in breast cancer survivors, which are reflected in the patient in this case study.
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Affiliation(s)
- Chinmeri U Achonu
- Faculty of Clinical Sciences, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Oluwarotimi B Olopade
- Department of Medicine, Endocrinology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Bashir O Yusuf
- Department of Medicine, Federal Teaching Hospital Katsina, Katsina, Nigeria
| | - Abimbola A Fadeyi
- Department of Radiodiagnosis, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Olufemi A Fasanmade
- Department of Medicine, Endocrinology, College of Medicine, University of Lagos, Lagos, Nigeria
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4
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Mitchell-Brown F, Gates C. Myxedema coma: Recognition and treatment. Nursing 2022; 52:17-21. [PMID: 35752902 DOI: 10.1097/01.nurse.0000832344.83659.a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Myxedema coma (MC) develops from a long-standing, unrecognized, or untreated hypothyroidism. This article discusses the pathophysiology, clinical manifestations, treatment, and nursing considerations for patients with MC.
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Affiliation(s)
- Fay Mitchell-Brown
- Fay Mitchell-Brown is an associate professor at the California State University at Chico, where Claire Gates is a nursing student
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5
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Nasrullah A, Azharuddin S, Young M, Kejas A, Dumont T. Endocrine Emergencies in the Medical Intensive Care Unit. Crit Care Nurs Q 2022; 45:266-284. [PMID: 35617093 DOI: 10.1097/cnq.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endocrine emergencies are underdiagnosed and often overlooked amid the management of severe multisystem pathologies in critically ill patients in the medical intensive care unit (ICU). In an appropriate clinical scenario, a low threshold of suspicion should be kept to investigate for various life-threatening, yet completely treatable, endocrinopathies. Prompt identification and treatment of endocrine emergencies such as diabetic ketoacidosis, myxedema coma, thyroid storm, and/or adrenal insufficiency leads to fewer complications, shorter ICU and hospital stay, and improved survival. This review article entails common endocrine emergencies encountered in the ICU and addresses their epidemiology, pathophysiology, clinical presentation and management.
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Affiliation(s)
- Adeel Nasrullah
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, Pennsylvania (Drs Nasrullah, Azharuddin, Young, and Dumont); and Department of Nursing, Allegheny Health Network, Pittsburgh, Pennsylvania (Ms Kejas)
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7
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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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8
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Renne SL, Valeri M, Radaelli S, Collini P, Barisella M. A recurrent mass on the big toe. Lancet Diabetes Endocrinol 2020; 8:868. [PMID: 32946823 DOI: 10.1016/s2213-8587(20)30309-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Salvatore L Renne
- Pathology Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Marina Valeri
- Pathology Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Stefano Radaelli
- Department of Surgery, Sarcoma Service, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paola Collini
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Marta Barisella
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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9
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Mohamed MF, Siepmann T, Suwileh S, Mohammed MH, Mohamed S, Abdalla LO, Elzouki AN, Mahmoud MH, Al-Mohanadi D, Danjuma M. Myxedema psychosis: A protocol for a systematic review and a pooled analysis. Medicine (Baltimore) 2020; 99:e20778. [PMID: 32590756 PMCID: PMC7328932 DOI: 10.1097/md.0000000000020778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Myxedema psychosis (MP) is a rare presentation of hypothyroidism. Although known for >70 years, a significant lack of systematic literature describing this condition exists. This limits the clinician's ability to identify and manage this entity properly. Hence, we aimed to systematically review the literature and summarize the presentation, diagnosis, management, and outcomes of this rare entity. METHODS Systematic review following PRISMA guidance. We will perform a comprehensive search of PubMed, Medline, Embase, Google Scholar (first 300 hits), and Cochrane databases for published observational studies, case series, and case reports. We will use descriptive statistics to provide summary estimates of demographics, common presenting features, laboratory test results, imaging findings, treatment administered, and outcomes. Moreover, continuous variables will be compared by the Wilcoxon Mann Whitney test, whereas categorical variables will be assessed by the χ test. Bivariate and multivariate regression will be performed to assess risk factors associated with poor outcome. A scoping review revealed that a meta-analysis might not be feasible owing to the paucity of systematic studies describing the condition. RESULTS This is the first systematic review examining this rare entity. Thus, the result of which will be significant. We hope that this review will help in identifying relevant predictive clinical or laboratory characteristics. Additionally, it identifies the best treatment strategies. The findings of this review will help increase our knowledge of this condition so as to recognize this condition promptly. Also, it will assist in differentiating MP from masqueraders, such as Hashimoto encephalopathy (HE). The results of this review will be published in a peer-reviewed journal. CONCLUSION This is the first systematic review exploring MP demographics, diagnosis treatment, and outcomes. The information gathered by this review will be necessary for patients, clinicians, researchers, and guideline makers. PROSPERO REGISTRATION NUMBER CRD42020160310.
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Affiliation(s)
- Mouhand F.H. Mohamed
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- Dresden International University Division of Health Care Sciences Center for Clinical Research and Management Education Dresden
| | - Timo Siepmann
- Dresden International University Division of Health Care Sciences Center for Clinical Research and Management Education Dresden
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Salah Suwileh
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Lina O. Abdalla
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Abdel-Naser Elzouki
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University
| | | | - Dabia Al-Mohanadi
- Primary Health Care Centers
- Endocrine Department, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Danjuma
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University
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10
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Abstract
Thyroid emergencies are rare life-threatening endocrine conditions resulting from either decompensated thyrotoxicosis (thyroid storm) or severe thyroid hormone deficiency (myxedema coma). Both conditions develop out of a long-standing undiagnosed or untreated hyper- or hypothyroidism, respectively, precipitated by an acute stress-associated event, such as infection, trauma, or surgery. Cardinal features of thyroid storm are myasthenia, cardiovascular symptoms, in particular tachycardia, as well as hyperthermia and central nervous system dysfunction. The diagnosis is made based on clinical criteria only as thyroid hormone measurements do not differentiate between thyroid storm and uncomplicated hyperthyroidism. In addition to critical care measures therapy focusses on inhibition of thyroid hormone synthesis and secretion (antithyroid drugs, perchlorate, Lugol's solution, cholestyramine, thyroidectomy) as well as inhibition of thyroid hormone effects in the periphery (β-blocker, glucocorticoids).Cardinal symptoms of myxedema coma are hypothermia, decreased mental status, and hypoventilation with risk of pneumonia and hyponatremia. The diagnosis is also purely based on clinical criteria as measurements of thyroid hormone levels do not differ between uncomplicated severe hypothyroidism and myxedema coma. In addition to substitution of thyroid hormones and glucocorticoids, therapy focusses on critical care measures to treat hypoventilation and hypercapnia, correction of hyponatremia and hypothermia.Survival of both thyroid emergencies can only be optimized by early diagnosis based on clinical criteria and prompt initiation of multimodal therapy including supportive measures and treatment of the precipitating event.
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Affiliation(s)
- C Spitzweg
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.
| | - M Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - R Gärtner
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
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11
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Tsai SL, Lin CC, Lin CY, Keng-Wei C, Chien CY. Comatose patient with hypothermia, dyspnea, and general edema in the emergency department: a case report. J Int Med Res 2018; 46:4338-4342. [PMID: 30111206 PMCID: PMC6166344 DOI: 10.1177/0300060518791074] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/05/2018] [Indexed: 11/17/2022] Open
Abstract
Patients presenting to the emergency department with hypothermia are rare and often require prompt diagnosis and management. Myxedema coma, which may cause severe hypothermia, is a true endocrine emergency requiring early and appropriate treatment. We report on a 47-year-old woman with a history of hyperthyroidism who underwent thyroidectomy 5 years previously, with no regular medication or examinations. She presented to the emergency department with a 1-month history of progressive dyspnea associated with general weakness. She also showed hypothermia, decreased mental status, and general edema. Echocardiography revealed increased pericardial effusion without tamponade. Laboratory examination suggested myxedema coma and hypothyroidism. She received thyroxine, glucocorticoid supplement, and intensive supportive care, after which she gradually improved and was discharged. This case suggests that myxedema coma should be considered in patients with hypothyroidism or a history of thyroidectomy who present with change in consciousness, hypothermia, or other symptoms related to critical or slow presentation in multiple organs. Moreover, long-standing hypothyroidism or precipitating acute events such as sepsis, cerebrovascular accidents, gastrointestinal bleeding, cold exposure, trauma, and some medications may also cause myxedema coma. Myxedema coma is associated with a high mortality, and patients suspected to be suffering from this condition should be treated without delay.
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Affiliation(s)
- Shang-Li Tsai
- Department of Emergency Medicine, Chang Gung Memorial Hospital,
Linkou, Taiwan
| | - Chi-Chun Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital,
Linkou, Taiwan
- Department of Emergency Medicine, Ton-Yen General Hospital,
Taiwan
| | - Cheng-Yu Lin
- Department of Emergency Medicine, Ton-Yen General Hospital,
Taiwan
| | - Chang Keng-Wei
- Department of Emergency Medicine, Ton-Yen General Hospital,
Taiwan
| | - Cheng-Yu Chien
- Department of Emergency Medicine, Chang Gung Memorial Hospital,
Linkou, Taiwan
- Department of Emergency Medicine, Ton-Yen General Hospital,
Taiwan
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12
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Horiuchi K, Nagai A, Wakita M, Ito S, Takamura K, Houzen H. Myasthenic Crisis Complicated with Myxedema, Positive for Both Anti-acetylcholine Receptor and Anti-muscle-specific Tyrosine Kinase Antibodies. Intern Med 2018; 57:265-268. [PMID: 29093409 PMCID: PMC5820048 DOI: 10.2169/internalmedicine.9291-17] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report the case of myasthenic crisis occurring in a 51-year-old man. He had experienced ptosis, increased body weight with edema, and fatigue with dyspnea. He presented at our emergency department with disturbed consciousness. He was originally diagnosed with myxedema coma, and he required artificial respiration. Because his weakness persisted and he was positive for anti-acetylcholine receptor antibodies and anti-muscle-specific tyrosine kinase antibodies, we diagnosed myasthenic crisis after various examinations. His clinical response to treatment was good and he was discharged in an ambulatory status 3 months after admission. This case demonstrates that myasthenic crisis may occur in association with myxedema.
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Affiliation(s)
| | - Azusa Nagai
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Masahiro Wakita
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Shotaro Ito
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Kei Takamura
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Hideki Houzen
- Department of Neurology, Obihiro Kosei General Hospital, Japan
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13
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Pangtey GS, Baruah U, Baruah MP, Bhagat S. Thyroid Emergencies: New Insight into Old Problems. J Assoc Physicians India 2017; 65:68-76. [PMID: 28799309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thyroid emergencies are major life-threatening endocrine conditions associated with life-threatening disorders resulting from either severe deficiency or excess of thyroid hormones. Deficiency of thyroid hormones may present as myxedema coma whereas excessive hormone production can present as life threatening thyrotoxic storm. The diagnosis of both requires a high index of clinical suspicion. Thyroid storm, in spite of accurate diagnosis, continues to have high fatality, whereas myxedema management has markedly improved with advancement in intensive care facility. The key to successful management of these emergencies is timely diagnosis and management by experienced physician in an intensive care setting. This article discusses the basic differences of both entities with an attempt to appropriate recognition and awareness of clinical signs and symptoms, highlight the salient diagnostic points and delineate the rational approach, which can lead to appropriate treatment at the earliest and reduce mortality.
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Affiliation(s)
| | - Udismita Baruah
- Senior Resident, Dept. of Anesthesia, VMMC & Safdurjung Hospital, New Delhi
| | - Manash P Baruah
- Senior Consultant, Excel Center (Excel Care Hospitals), Guwahati, Assam
| | - Sahil Bhagat
- Senior Resident, Dept. of Medicine, LHMC and Associated Hospitals, New Delhi
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14
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Abstract
RAIONALE Myxedema coma (MC) is extremely rare but lethal in pediatric patients with hypothyroidism leading to altered mental status and hypothermia. But there is no clinical guideline for such cases. PATIENT CONCERNS A 6-year-old Chinese girl presented with coma and hypothermia preceded by pneumonia. Her lab results were: free thyroxin (T4) 4.18 pmol/L and thyroid-stimulating hormone (TSH) > 150 μIU/mL with extremely elevated anti-thyroid peroxidase (TPO-Ab) and anti-thyroglobulin. Pneumonia, mild pleural, and pericardial effusion were seen on computed tomographic (CT) scan. DIAGNOSES MC, autoimmune hypothyroidism, pneumonia and sepsis were diagnosed. INTERVENTION Gastric levothyroxine, intravenous dexamethasone and antibiotics were administered. OUTCOME Her consciousness was restored and temperature returned to normal 2 days after starting levothyroxine. She was discharged two weeks later. CONCLUSION MC is rare but may be the initial presentation in pediatric patients with prolonged untreated hypothyroidism. Autoimmune thyroiditis could cause hypothyroidism in children. MC should be suspected in pediatric patients with altered mental status, hypothermia and cardiovascular instability. Treatment with 100 mg/m of gastric levothyroxine is an option for pediatric patients with MC.
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Affiliation(s)
- Yueniu Zhu
- Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology/Genetics, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute for Pediatric Research, Shanghai, China
| | - Mengyan Deng
- Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine
| | - Xiaodong Zhu
- Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine
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15
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Akpalu J, Atiase Y, Yorke E, Fiscian H, Kootin-Sanwu C, Akpalu A. Challenges in the Management of a Patient with Myxoedema Coma in Ghana: A Case Report. Ghana Med J 2017; 51:39-42. [PMID: 28959072 PMCID: PMC5611947 DOI: 10.4314/gmj.v51i1.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Myxoedema coma is a rare life-threatening disease, and it is essential that it is managed appropriately to reduce the associated high mortality. However, in the setting where efficient healthcare delivery is hampered by inadequacies, the management of such cases may pose a significant challenge. We present the case of a middle-aged woman diagnosed with myxoedema coma and severe hyponatremia. The case report highlights some of the challenges that may be encountered during the management of myxoedema coma in similar settings and outlines the management strategies undertaken to overcome them in the absence of national guidelines. It also brings to the fore the need for clinicians to look out for clinical features suggestive of hypothyroidism particularly among high risk individuals for early diagnosis and treatment. FUNDING None declared.
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Affiliation(s)
- Josephine Akpalu
- Endocrinology Unit, Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, P.O. Box GP 4236, Accra, Ghana
| | - Yacoba Atiase
- Endocrinology Unit, Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, P.O. Box GP 4236, Accra, Ghana
| | - Ernest Yorke
- Endocrinology Unit, Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, P.O. Box GP 4236, Accra, Ghana
| | - Henrietta Fiscian
- Endocrinology Unit, Korle Bu Teaching Hospital, P.O. Box KB 77, Korle Bu
| | | | - Albert Akpalu
- Neurology Unit, Department of Medicine and Therapeutics, School of Medicine and Dentistry, University of Ghana, PO Box GP 4236, Accra, Ghana
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16
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Herskovitz I, Hughes O, MacQuhae F, Kirsner RS. Pretibial Myxedema Masquerading as a Venous Leg Ulcer. Wounds 2017; 29:77-79. [PMID: 28355140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The authors report a case of pretibial myxedema (PTM) masquerading as a venous leg ulcer to alert wound care clinicians to this diagnostic possibility. Pretibial myxedema is a localized form of mucin cutaneous deposition characterized by indurated plaques most commonly on anterior legs. It is more likely to present in patients with Graves' disease, but it can be found in euthyroid patients as well. The physiopathology of PTM is complex, and there is an accumulation of highly hydrophilic glycosaminoglycans in the dermis. Minimal morbidity is associated with PTM, but the pruritus related to mucin deposition can be intense. The skin around venous leg ulcers and the skin changes related to PTM can have a similar clinical presentation, which may be a reason PTM is under-recognized.
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Affiliation(s)
- Ingrid Herskovitz
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Olivia Hughes
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Flor MacQuhae
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
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17
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Rizzo LFL, Mana DL, Bruno OD, Wartofsky L. [Myxedema coma]. Medicina (B Aires) 2017; 77:321-328. [PMID: 28825577] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.
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Affiliation(s)
| | - Daniela L Mana
- Dirección Médica Química Montpellier SA, Buenos Aires, Argentina. E-mail:
| | - Oscar D Bruno
- Fundación de Endocrinología, Buenos Aires, Argentina
| | - Leonard Wartofsky
- Department of Medicine, Washington Hospital Center, Washington, DC, USA
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18
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Abstract
Background: Animal studies have shown that some human monoclonal antibodies promote myelin repair in models of demyelinating disease. Scleromyxedema is a dermatologic disorder associated with a monoclonal gammopathy and neurologic manifestations. The reason for occurrence of cutaneous reactio ns in interferon treated patients is unknown. Case description: A 37-year-o ld woman was started on weekly interferon beta-1a (IFN beta-1a) following a diagnosis of multiple sclerosis (MS). A fter having been on interferon therapy for three years, she developed skin lesions secondary to scleromyxedema. Her IFN beta-1a was discontinued and intravenous immunoglobulin therapy was started for her scleromyxedema. A t a six-month follow up, her skin lesions improved and there was no recurrence of neurologic symptoms. Conclusions: This is the first report of occurrence of scleromyxedema in a patient with MS. While this could be a chance association, it does raise the question if her neurologic manifestations could be secondary to scleromyxedema. Further research into the mechanism of IFN related cutaneo us side effects is needed. Evidence regarding the remyelinating nature of human monoclonal antibodies raises interest in the potential therapeutic role these antibodies may have.
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Affiliation(s)
- Neeraj Kumar
- Department of Neurology, Mayo Medical and Graduate Schools, Rochester, MN 55905, USA.
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19
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Affiliation(s)
- Xiaoying Chen
- Department of Dermatology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, 200025 Shanghai, China
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Fjølner J, Søndergaard E, Kampmann U, Nielsen S. Complete recovery after severe myxoedema coma complicated by status epilepticus. BMJ Case Rep 2015; 2015:bcr2014209071. [PMID: 25809434 PMCID: PMC4386296 DOI: 10.1136/bcr-2014-209071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 11/03/2022] Open
Abstract
We report a case of life-threatening myxoedema presenting with hypothermia, hypotension, bradycardia, pericardial effusion and deep coma. The condition was complicated by prolonged status epilepticus. The optimal treatment strategy has been debated over the years and the literature is briefly reviewed. Treatment with l-thyroxine (LT4) monotherapy without initial loading dose and with no l-triiodothyronine (LT3) treatment was successful with full recovery after hospitalisation for more than a month. Myxoedema coma is a rare, reversible condition with a high mortality and should be considered as a differential diagnosis in medical emergencies.
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Affiliation(s)
- Jesper Fjølner
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus C, Denmark
| | - Esben Søndergaard
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Ulla Kampmann
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Søren Nielsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus C, Denmark
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21
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Abstract
This review presents current knowledge about the thyroid emergencies known as myxedema coma and thyrotoxic storm. Understanding the pathogenesis of these conditions, appropriate recognition of the clinical signs and symptoms, and their prompt and accurate diagnosis and treatment are crucial in optimizing survival.
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Affiliation(s)
- Joanna Klubo-Gwiezdzinska
- Division of Endocrinology, Department of Medicine, Washington Hospital Center, Washington, DC 20010-2910, USA
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22
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Affiliation(s)
- Ying-Yi Lu
- Department of Dermatology, Kaohsiung Veterans General Hospital, Taiwan
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23
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24
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Shah SN. Thyroid emergencies. J Assoc Physicians India 2011; 59 Suppl:66. [PMID: 21819006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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25
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Konishi M, Morita K, Tanaka Y. [Therapy-resistant thyroid diseases. 3. Myxedema coma]. Nihon Naika Gakkai Zasshi 2010; 99:769-775. [PMID: 20578364 DOI: 10.2169/naika.99.769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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26
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DOORENBOS H, BAKKER A, WOLDRING MG. Red Cell Triiodothyronine Uptake in Relation to the Result of Treatment in Thyrotoxicosis and Myxedema. Acta Medica Scandinavica 2009; 171:357-63. [PMID: 13887309 DOI: 10.1111/j.0954-6820.1962.tb04199.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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27
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Senel E, Güleç AT. Euthyroid pretibial myxedema and EMO syndrome. Acta Dermatovenerol Alp Pannonica Adriat 2009; 18:21-23. [PMID: 19350184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
EMO syndrome is a rare extrathyroid syndrome, seen in only 1% of patients affected by extrathyroid complications of Graves' disease. A 73-year-old woman presented with a 1-year history of asymptomatic local swellings on her legs and feet. Physical examination revealed moderate proptosis and multiple, firm subcutaneous nodules of 1 to 5 cm in diameter located on the anterior and medial aspects of the shins and on feet. The patient had a history of bilateral knee arthroplasty 5 years ago. Histopathologic examination showed deposition of mucin and perivascular lymphocytic infiltration in the dermis. Dermatologic and pathologic findings were consistent with pretibial myxedema. Laboratory tests showed normal thyroid stimulating hormone (TSH) and serum free T3 and T4 levels. The TSH receptor antibody titer was elevated. Thus, with all these findings she was diagnosed with exophthalmia, myxedema, and hypertrophic osteoarthropathy (EMO) syndrome. The lesions were completely treated with three monthly intralesional corticosteroid injections and at the 4-month follow-up no recurrence was observed. Only three euthyroid cases with pretibial myxedema have been reported in the literature. Patients that have asymptomatic pretibial nodular or plaque lesions should be investigated with an ophthalmologic examination and laboratory workup to clarify a possible underlying thyroid gland disease and EMO syndrome.
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Affiliation(s)
- Engin Senel
- Baskent University Faculty of Medicine, Department of Dermatology, 5. sokak No: 48 Bahcelievler, Ankara, Turkey.
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28
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Szolnoky G, Bársony K. Complex decongestive physiotherapy for pretibial myxoedema. Aust J Physiother 2009; 55:227. [PMID: 19681753 DOI: 10.1016/s0004-9514(09)70101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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29
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Syed AA, Jones NAG, Perros P. Medical image. Acute pretibial myxoedema following thyroidectomy for Graves' disease. N Z Med J 2008; 121:108-109. [PMID: 18841193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Akheel A Syed
- Salford Royal NHS Foundation Trust, Salford M6 8HD, United Kingdom.
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30
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Husebye ES. [Endocrinologic emergency medicine]. Tidsskr Nor Laegeforen 2008; 128:574. [PMID: 18333289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
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31
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Mistovich JJ, Krost WS, Limmer DD. Beyond the basics: endocrine emergencies. Part 2: hypothyroidism and myxedema coma. EMS Mag 2007; 36:66-71. [PMID: 18044399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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32
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Abstract
Untreated or unrecognized hypothyroidism may progress to severe decompensated hypothyroidism or myxedema coma. Relatively few cases are reported in the literature since the first case was apparently reported from the St. Thomas Hospital in London in 1879. The paucity of cases may be due to either underreporting or improvement in the diagnosis and treatment of uncomplicated hypothyroidism. However, despite the ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a challenge. Although thyroid hormone treatment is highly effective when combined with ventilatory and hemodynamic support in the intensive care unit setting, controversies abound on the optimal and most effective choice of thyroid hormone preparation: thyroxine and triiodothyronine and in what amount. Accumulated evidence now shows that proper use of either thyroxine alone or in combination with triiodothyronine may be effective therapy.
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Affiliation(s)
- Maxwell P Kwaku
- Endocrine Section, Washington Hospital Center, Washington, DC 20010-2975, USA
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33
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Cappelli C, Stanga B, Paini A, Gandossi E, Cumetti D, Castellano M, Muiesan ML, Agabiti Rosei E. Myxoedema coma precipitated by diabetic ketoacidosis and neuroleptic drugs: case report in an intensive care unit. Intern Emerg Med 2007; 2:147-9. [PMID: 17634822 DOI: 10.1007/s11739-007-0045-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Accepted: 09/19/2006] [Indexed: 10/23/2022]
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34
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Abstract
Endocrine emergencies constitute only a small percentage of the emergency workload of general doctors, comprising about 1.5% of all hospital admission in England in 2004-5. Most of these are diabetes related with the remaining conditions totalling a few hundred cases at most. Hence any individual doctor might not have sufficient exposure to be confident in their management. This review discusses the management of diabetic ketoacidosis, hyperosmolar hyperglycaemic state, hypoglycaemia, hypercalcaemia, thyroid storm, myxoedema coma, acute adrenal insufficiency, phaeochromocytoma hypertensive crisis and pituitary apoplexy in the adult population.
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Affiliation(s)
- T Kearney
- Hope Hospital, Stott Lane, Salford M6 8HD, UK.
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35
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Kureshi F, Davis MDP, Burkemper NM, Weenig RH, Pittelkow MR, Gamble GL. Thyroid dermopathy: an underrecognized cause of leg edema. Cutis 2007; 79:219-24. [PMID: 17674588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Leg edema is a common clinical problem and the differential diagnosis is extensive. We present 4 patients in whom thyroid dermopathy was the cause of leg edema. Examination of the eyes and the nature of the edema were clues to the diagnosis of thyroid dermopathy. Clinical signs should be documented and analysis of skin biopsy specimens should be performed in patients suspected to have thyroid dermopathy.
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Affiliation(s)
- Faraz Kureshi
- Departments of Dermatology and Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
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36
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37
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Abstract
Myxedema coma is the term given to the most severe presentation of profound hypothyroidism and is often fatal in spite of therapy. Decompensation of the hypothyroid patient into a coma may be precipitated by a number of drugs, systemic illnesses (eg, pneumonia), and other causes. It typically presents in older women in the winter months and is associated with signs of hypothyroidism, hypothermia, hyponatremia, hypercarbia, and hypoxemia. Treatment must be initiated promptly in an intensive care unit setting. Although thyroid hormone therapy is critical to survival, it remains uncertain whether it should be administered as thyroxine, triiodothyronine, or both. Adjunctive measures, such as ventilation, warming, fluids, antibiotics, pressors, and corticosteroids, may be essential for survival.
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Affiliation(s)
- Leonard Wartofsky
- Department of Medicine, Washington Hospital Center, Washington, DC 20010-2975, USA.
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38
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Vadász J. [Diagnosis and management of endocrine crises in adulthood]. Orv Hetil 2006; 147:2117-24. [PMID: 17209300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Diagnosis and management of endocrine crises in adulthood. The homeostasis of the body is regulated by concerted action of the endocrine, nervous and immune systems. An imbalance in this equilibrium, as a consequence of disease or endocrine failure, may lead to crisis, characterized by sudden onset and severe symptoms. The classical endocrine emergencies are rare but life-threatening conditions. Prompt and aggressive treatment significantly reduces mortality. Immediate therapy might be necessitated in cases of suspected endocrine emergencies, even prior to laboratory confirmation. These patients generally require admittance to an intensive care unit. In the present review only the most severe forms of life-threatening endocrine emergencies, including acute adrenal insufficiency, pituitary apoplexy, pheochromocytoma crisis, thyroid storm and myxedema coma will be discussed.
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Affiliation(s)
- János Vadász
- Jász-Nagykun Szolnok Megyei Hetényi Géza Kórhaz-Rendelointézet, III. Belgyógyászati Osztály, Szolnok
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39
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Abstract
Whereas Sir Victor Horsley is well known for his many contributions to neurosurgery, this is not the case for his treatments for both myxedema and cretinism. Horsley's research on thyroid physiology was concentrated in the years 1884-1890, while he was director of the Brown Institute for Animals. Based upon experimentation with dogs and monkeys as well as some human patients, Horsley demonstrated conclusively that removal of the thyroid gland produced tremors, rigidity, and paralysis, which he attributed to changes in lower motor centers. Furthermore, the development of imbecility suggested that thyroid excision produced deficits in higher cortical functioning. Horsley showed that it was possible to alleviate temporarily some of the psychological and physiological symptoms of both myxedema and cretinism using transplanted thyroid tissue. Several of Horsley's students, most notably George Murray, continued and extended his work by examining other ways in which myxedema and cretinism could be treated (e.g., by injecting an extract of thyroid tissue).
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Affiliation(s)
- Sheryl R Ginn
- Department of Psychology, Wingate University, Wingate, North Carolina, USA
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40
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Illa I, de la Torre C, Rojas-Garcia R, Altes A, Blesa R, Sierra J, Gallardo E. Steady remission of scleromyxedema 3 years after autologous stem cell transplantation: an in vivo and in vitro study. Blood 2006; 108:773-4. [PMID: 16822907 DOI: 10.1182/blood-2006-01-0186] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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41
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Nomura E, Toyoda N, Nishikawa M. [Idiopathic myxedema * atrophic thyroiditis]. Nihon Rinsho 2006; Suppl 1:333-6. [PMID: 16776158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Emiko Nomura
- The Second Department of Internal Medicine, Kansai Medical University
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42
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Shimura H, Endo T, Kobayashi T. [EMO syndrome]. Nihon Rinsho 2006; Suppl 1:311-5. [PMID: 16776152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Hiroki Shimura
- Third Department of Internal Medicine, University of Yamanashi
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43
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Tsuboi K, Ueshiba H. [Myxedema coma]. Nihon Rinsho 2006; Suppl 1:344-7. [PMID: 16776161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Kumiko Tsuboi
- Division of Diabetes, Metabolism and Endocrinology, Department of Medicine, Toho University School of Medicine
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Abstract
Pretibial myxedema or localized myxedema or thyroid dermopathy is an autoimmune manifestation of Graves' disease. It also occasionally occurs in Hashimoto's thyroiditis. Lesions of thyroid dermopathy are usually asymptomatic and have only cosmetic importance. Advanced forms of dermopathy are associated with elephantiasis or thyroid acropachy. Almost all cases of thyroid dermopathy are associated with relatively severe ophthalmopathy. Usually ophthalmopathy appears first and dermopathy much later. All patients with localized myxedema have high serum concentrations of thyroid-stimulating hormone receptor antibodies, indicating the severity of the autoimmune condition. Occurrence of thyroid dermopathy in areas other than pretibial skin indicates a systemic process. Similar to Graves' ophthalmopathy, thyroid-stimulating hormone receptors in the connective tissue may be the antigen responsible for the immune process. Both humoral and cellular immune mechanisms are involved in the stimulation of fibroblasts and the production of large amounts of glycosaminoglycans. Localization in the pretibial area relates to mechanical factors and dependent position. Diagnosis of thyroid dermopathy is based on signs and typical pretibial skin lesions in association with a history of Graves' hyperthyroidism and ophthalmopathy. In some cases, skin biopsy is needed for confirmation. The lesions are usually mild and are overshadowed by more symptomatic ophthalmopathy. Most cases of thyroid dermopathy do not require any therapy. In mildly severe symptomatic cases and when there is cosmetic concern, topical corticosteroids applied under occlusive dressing are beneficial. In more severe cases, systemic immunomodulation may be necessary; however, conclusive evidence for long-term efficacy of these modalities is lacking. When significant edema and elephantiasis are present, local compressive therapy may have added benefit. In mild cases that do not require treatment, 50% of patients achieve complete remission after several years. Severe cases that receive topical corticosteroids or other therapies do not have a better outcome than untreated milder cases. Current treatment modalities for thyroid dermopathy and acropachy are at best palliative. Better and safer means of immunomodulation are needed.
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Affiliation(s)
- Vahab Fatourechi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
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45
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Kinjo Y, Kouki T, Komiya I, Takasu N. [Development of pretibial myxedema after radioisotope (I131) treatment in a Graves' patient]. Nihon Naika Gakkai Zasshi 2006; 95:127-9. [PMID: 16499217 DOI: 10.2169/naika.95.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Yoshino Kinjo
- University of Ryukyus, Faculty of Medicine, Department of Endocrinology and Metabolism, Nakagami
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46
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Jolles S, Hughes J. Use of IGIV in the treatment of atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis, and pretibial myxedema. Int Immunopharmacol 2005; 6:579-91. [PMID: 16504920 DOI: 10.1016/j.intimp.2005.11.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There has been a rapid expansion in the use of IGIV for an ever-growing number of conditions. It is a product with an excellent safety record without the side effects of steroids or other immunosuppressive agents. There have been numerous recent advances in our understanding of the mechanisms of action of IGIV in many of the conditions for which it is being used, but there is still much to be learned. IGIV has had a major impact in neurology, haematology, immunology, rheumatology and dermatology. The limitations for IGIV are cost of the preparation itself and the logistical problems associated with its administration. Here we describe the published evidence for the use of high-dose IGIV in the dermatological conditions atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis and pretibial myxedema. These conditions have an emerging evidence base for hdIGIV which is relatively small consisting mainly of case reports and small case series. The outcomes in a number of these conditions appear encouraging, but as the reports are likely to reflect a bias for positive results, one must be cautious about drawing firm conclusions.
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Affiliation(s)
- Stephen Jolles
- National Institute for Medical Research, Mill Hill, London and University Hospital of Wales, Cardiff, UK.
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47
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Donato ML, Feasel AM, Weber DM, Prieto VG, Giralt SA, Champlin RE, Duvic M. Scleromyxedema: role of high-dose melphalan with autologous stem cell transplantation. Blood 2005; 107:463-6. [PMID: 16179379 PMCID: PMC1895605 DOI: 10.1182/blood-2004-12-4870] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Scleromyxedema, the most severe manifestation of the spectrum of lichen myxedematosus, is characterized by cutaneous mucinosis, extracutaneous manifestations, and a monoclonal gammopathy. Seven of 8 patients evaluated at our center were treated with high-dose melphalan (180 mg/m(2) intravenously) and autologous peripheral blood stem cell transplantation, with marked improvement of gastrointestinal, central nervous system, pulmonary manifestations, and Karnofsky performance status. Five patients obtained a cutaneous complete remission and 2 patients had partial remissions. Three patients with slight progression in the skin at 12, 8, and 4 months after treatment received a second cycle of high-dose melphalan and had further symptomatic improvement. The lichen myxedematosus-scleromyxedema spectrum appears to be a continuum that requires the presence of a serum paraprotein and differs in severity of skin lesions, extracutaneous manifestations, and performance status. High-dose melphalan followed by autologous transplantation appears effective for improving the symptoms and systemic manifestations of scleromyxedema.
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Affiliation(s)
- Michele L Donato
- Department of Blood and Bone Marrow Transplantation, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030-4009, USA
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48
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Larsen K. [Stewed glands as hormone therapy]. Ugeskr Laeger 2005; 167:3515; author reply 3515-6. [PMID: 16159470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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49
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Proust-Lemoine E, Vantyghem MC, Bauters C, Nocaudie M, Wémeau JL. [Severe Graves' acropachy and dermopathy. Three case reports]. Presse Med 2005; 34:367-70. [PMID: 15859571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
INTRODUCTION Traditionally described, severe Graves' acropachy and tibial myxoedema are now only encountered in certain severe forms of Graves' disease, where they can be difficult to diagnose and hence delay the initiation of treatment. OBSERVATIONS Three patients presented with severe ophthalmopathy, pretibial myxoedema and acropachy of different clinical forms. DISCUSSION In supplement to the usual biopsies and X-rays, bone scintigraphy provides early diagnosis of acropachy. The severity of the immune disease, the episodes of hypothyroidism and cigarette smoking are the 3 main factors contributing to these extra-thyroid manifestations of Graves' disease. There is currently no treatment that can permanently resolve the functional and aesthetic problems of dermopathy and acropachy.
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Breuckmann F, Freitag M, Rotterdam S, Stuecker M, Altmeyer P, Kreuter A. Immunohistochemical investigations and introduction of new therapeutic strategies in scleromyxoedema: case report. BMC Dermatol 2004; 4:12. [PMID: 15385052 PMCID: PMC522804 DOI: 10.1186/1471-5945-4-12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2004] [Accepted: 09/22/2004] [Indexed: 12/02/2022]
Abstract
Background Scleromyxoedema is a rare chronic skin disease of obscure origin, which may often be associated with severe internal co-morbidity. Even though different casuistic treatment modalities have been described, to date, curing still seems to be impossible. Case presentation We report a 44-year-old Caucasian female presenting with remarkable circumscribed, erythematous to skin-coloured, indurated skin eruptions at the forehead, arms, shoulders, legs and the gluteal region. Routine histology and Alcian blue labelling confirmed a massive deposition of acid mucopolysaccharides. Immunohistochemical investigations revealed proliferating fibroblasts and a discrete lymphocytic infiltration as well as increased dermal expression of MIB-1+ and anti-mastcell-tryptase+ cells. Bone marrow biopsies confirmed a monoclonal gammopathy of undetermined significance without morphological characteristics of plasmocytoma; immunofixation unveiled the presence of IgG-kappa paraproteins. Conclusions Taking all data into account, our patient exhibited a complex form of lichen mxyoedematosus, which could most likely be linked a variant of scleromyxoedema. Experimental treatment with methotrexate resulted in a stabilisation of clinical symptoms but no improvement after five months of therapy. A subsequent therapeutic attempt by the use of medium-dose ultraviolet A1 cold-light photomonotherapy led to a further stabilisation of clinical symptoms, but could not induce a sustained amelioration of skin condition.
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Affiliation(s)
- Frank Breuckmann
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Marcus Freitag
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Sebastian Rotterdam
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Markus Stuecker
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Peter Altmeyer
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Alexander Kreuter
- Department of Dermatology, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
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