Abstract | April 5, 2022

Myxedema Coma: An Atypical Presentation

Presenting Author: Alexey Finkelshteyn, MD, FM Resident PGY3, Family Medicine, Houston Healthcare Center, Bonaire, GA

Learning Objectives

  1. Upon completion of this lecture, learners should be better prepared to appreciate the complexity of the Myxedema Coma presentation, the differential diagnosis, the importance of thorough patient history research, and the management of all the endocrinological maladies that need attention in that case

I) Case Presentation
a. 52 yo CM w/PMH: HTN, CKD3, hypothyroidism, polysubstance abuse (EtOH, meth, MJ)
i. lethargic…family called EMS, Hallucinating during transport
ii. Home Meds-Trazodone, Pravastatin, Montelukast, Levothyroxine, HCTZ, Buspar, Albuterol, Lactulose
iii. Past Surgical History:
1. Left Thyroidectomy 2013–papillary carcinoma, follicular variant with nodular hyperplasia, Hurthle cells
2. Right Thyroidectomy 1980
b. Physical exam
i. 91.5 F (rectal), HR 56, BP 92/55, RR 18, O2 sat 90% on BIPAP
ii. Gen-disheveled, middle aged, non-responsive
iii. HEENT-NC, atraumatic, anicteric
iv. Neck-supple, w/o LA,JVD,Goitre
v. Cardio-bradycardic, RRR, no m/r/g vi. Pulm-CTAB
vii. Abdomen-BS present
viii. Extremities-swollen and erythematous bilaterally to knees, no clubbing, cyanosis
c. DDx
i. Shock-septic vs drug-induced vs hypovolemia
1. UTI/Pneumonia
ii. Substance Abuse/Overdose
iii. Acute on Chronic HFrEF
iv. Hypoxic, hypercapnic respiratory failure d/t COPD exacerbation
v. Hypothyroid Crisis d/t medication non-compliance
d. Tests/Results
i. WBC-3.1, Hgb 9.9, Hct 30.1, MCV 101.5
ii. ABG-7.29/PCO2 68/PaO2 121/BiCarb 35, lactic acid 1.0
iii. Chemistry-Na 138, K 4.4, Cl 102, CO2 32, AG 4, BUN 25, Cr 1.64, GFR 44, glucose 87, Osm 277.7, Ca 7.9, Mg 2.6, AST 1037, ALT 586, protein 5.9, BNP 137, procalcitonin 1.17 TSH >49.5
iv. Urine-hazy w/LE, protein, urobilinogen, WBC, epithelial cells, phosphate crystals, hyaline casts, urine mucus
v. UDS (+) amphetamine, marijuana
vi. Abdominal U/S–hepatic steatosis, 2 hyperechoic foci R lobe liver, ascites
vii. CXR–bronchopneumonia, LLL atelectasis, venous congestion, pulmonary edema
viii. NC Head CT-negative
ix. Echocardiogram–EF 40-45%, MR, TR
II) Final/Working Diagnosis
a. Myxedema Coma d/t non-compliance
III) Management
a. Intensive care : Airway Support with Pulm/Critical Care
i. management of airway from aspiration: altered sensorium highest priority
ii. Endotracheal intubation/tracheostomy with mechanical ventilation with regular monitoring of ABG
b. fluid management: correct hypotension – Pressors vs Fluids
c. Consultation Endocrinology
d. Thyroid hormone replacement IV
e. Hyponatremia: may need hypertonic saline with diuretic
f. SIADH: may need vasopressin receptor antagonist
g. Adrenal insufficiency – supplementation with IV corticosteroids
h. Speech and language pathology
IV) Outcome/Follow-Up
a. Consider D/C w/home health/Skilled nursing/PT
b. Close outpatient f/u with routine TSH to optimize