Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

PROLACTINOMA WITH EPISODES OF HYPOTHERMIA PRODUCING NEW HEART BLOCK IN FEMALE PATIENT Isabel Lewis, OMSIII*, Maisie Kramer, OMSIII*, Chelsea McCoy, DO Edward Via College of Osteopathic Medicine, Carolinas Campus, Spartanburg, SC Newberry County Memorial Hospital *Equal Contribution

Abstract

Results

Conclusions

Figure 2. MRI of Prolactinoma Image showing residual evidence of prolactinoma being actively treated with cabergoline. Initial diagnosis in 2012 indicating a 2cm suprasellar mass consistent with a macroprolactinoma

Context : A 96-year-old African American woman with a known prolactinoma presented to the Emergency Room on several occasions after developing mild hypothermia with subsequent altered mental status and Mobitz II second degree heart block. After warming the patient to a euthermic state, her altered mental status resolved and heart rhythm returned to first degree heart block, her normal baseline. Report of Case : This patient has a past medical history significant for hypertension, prolactinoma, first degree heart block, and thyroidectomy presented on four occasions to the ED for altered mental status and hypothermia. Throughout her four admissions, initial core body temperature ranged from 90.9-93.7 degrees Fahrenheit, with blood pressure ranging from 70/30 to 110/54 upon admission. She was given warmed IV fluids in addition to the use of either a Bair Hugger or Stryker blanket for rewarming. Each admission was approximately two to three weeks after the previous one, each with similar presentations upon arrival to the ED. On one admission, EKG showed bradycardia with new onset Mobitz II second degree heart block. She was monitored on tele-strip and treated for her active problems in the hospital, during which her new onset heart block resolved once her hypothermia had resolved, with EKG showing her baseline of first-degree heart block. Her subsequent admissions were complicated by her increasing dementia resulting in her refusing to take her oral medications, including her cabergoline and levothyroxine. By treating her hypothermia and any other presenting problems, her mentation would improve, but would again gradually decline upon discharge. Due to the undertreatment of her prolactinoma and hypothyroidism, her temperature control was greatly altered, resulting in her repeated admissions for hypothermia and subsequent new heart block. Ultimately, on her final admission, it was decided by family that the patient should discharge with hospice services with the intent being to decrease the need for her to be readmitted. Comments : It is well established in medical literature that hypothermia can result in EKG changes such as J waves, interval prolongation, and other arrhythmias. It is also known that pituitary tumors and hypothyroidism can have effects on temperature control. Reports published in the NIH have documented such occurrences of temperature dysregulation as well as the cardiac changes as discussed, but no cases have been reported combining the two findings. Hypothermia is defined as an unintended bodily temperature drop below 35 degrees Celsius. The body maintains a homeostatic temperature of approximately 37 degrees Celsius through a part of the brain called the hypothalamus, which interprets signals from the rest of the body and induces the proper response to the external environment. Severe complications of hypothermia include arrhythmias, organ failure, and death 1. In this case, we will be primarily focusing on the cardiac complications of hypothermia. A person is at risk for cardiac problems when their temperature drops below 32 degrees Celsius. Sinus bradycardia, Osborn waves, and different types of heart block are common EKG findings in severe hypothermia that is indicative of first-degree heart block 2 . Maintaining bodily temperature is important for homeostasis and hypothermia can have negative impacts on multiple organ systems. The thyroid gland helps regulate many different functions in the human body, one of which being temperature control. Thyroid hormone increases metabolism for energy in various tissues and sympathetic-associated thermogenesis 3. Insufficient levels of thyroid hormone is known as hypothyroidism. Common characteristics of hypothyroidism include, but are not limited to, fatigue, weight, and cold tolerance. A rare but morbid complication of hypothyroidism is myxedema coma. Myxedema coma can manifest on a spectrum but is consistently characterized as multiple organ issues and severe mental deterioration. This severe complication often has a precipitating event with common initiators including trauma, hypoglycemia, hypothermia, and infection. A significant adverse event of myxedema is its negative impacts on cardiac function. Bradycardia and hypotension are the most common signs, but heart block arrhythmias have also been documented 4 . In one case report, a young adult male who had been diagnosed with hypothyroidism presented with suspected myxedema coma and an intermittent Mobitz II second degree heart block. That patient was treated successfully with oral and IV levothyroxine 5 . Regulation of thyroid hormone is crucial because subclinical levels can lead to hypothermia, cardiac arrhythmias, and sudden death. Second degree heart block, Mobitz Type II occurs when the conducting signal from the AV node fails to conduct to the ventricles. This presents on EKG as an occasionally dropped QRS complex with a normally spaced PR interval. Causes of Mobitz Type II heart block include anterior wall myocardial infarction, fibrotic diseases, electrolyte imbalances, and certain medications. This type of second-degree heart block is cause for concern because it can progress to third degree heart block or even cause sudden death due to the randomness in which the P wave fails to conduct 6 . Second degree heart block is a serious condition with a multitude of causes. Diagnosis : Prolactinoma and Hypothyroidism complicated by Hypothermia with Second Degree Heart Block . Introduction

It is well-established that hypothyroidism can lead to hypothermia, both of which can cause cardiac arrythmias and altered mental status. In the presence of dementia, existing medical conditions can be worsened due to the patient’s decreasing ability to care for themselves. Thyroid hormone regulation is a multifactorial process and requires many parts of the body to be functioning properly. In the presence of multiple co morbidities, determining the root cause can prove to be difficult. Mobitz II second degree heart block is commonly caused by myocardial infarctions, electrolyte imbalances, and other cardiomyopathies. Hypothermia is not a common cause listed in literation. However, upon thermal and fluid resuscitation in our patient, her heart block would return to normal, leading us to believe that was the cause of her newly onset heart block. We are suspicious that our patient suffered from myxedema coma based on her unique presentation of Mobitz II heart block, altered mental status, and hypothermia in the presence of hypothyroidism and macroprolactinoma. We are unable to confirm our hypothesis due to the patient’s choice to initiate hospice treatment and subsequent passing.

Table 1. Temperature on arrival per hospital admission Due to the patient's advanced dementia, she often would refuse or be unable to take her medications. In the absence of her cabergoline and levothyroxine, temperature regulation proved very difficult, and a Bair Hugger was needed throughout each admission. On her initial admission on 08/28/2023, she presented at the Emergency Department after a fall at home where she was found to also be hypothermic with a creatine kinase (CK) of 3289, blood urea nitrogen (BUN) of 51, and creatinine (Cr) of 1.8. She was then admitted to the intensive care unit (ICU) for management of rhabdomyolysis, acute kidney injury (AKI), and hypothermia. On 9/26/2023, she was admitted for a second time with chief complaints of difficulty walking and diarrhea. Upon evaluation, she was found to be hypothermic and dehydrated with criteria meeting the diagnosis of AKI. Her EKG revealed new onset Mobitz Type II heart block After fluid resuscitation and use of a Stryker blanket, her AKI, arrhythmia, and hypothermia were resolved. On her admission on 10/29/2023, she presented with hypothermia, hypotension (BP 70/30), and was found to have evidence of pneumonia on chest x-ray. She was discharged to inpatient rehab to build strength prior to going home with family. She was re-admitted to the hospital on 11/11/2023 for continued hypothermia with new onset of altered mental status per family. On admission evaluation, she was found to have bilateral pleural effusions on chest x-ray, most likely a complication from her previously diagnosed pneumonia. It was on this admission that the decision was made to transition to hospice for palliative care.

Admission Date

Temperature on Arrival

08/28/2023 09/26/2023 10/29/2023 11/11/2023

92.8 Fahrenheit 91.3 Fahrenheit 91.0 Fahrenheit 90.1 Fahrenheit

Figure 3. Example of Mobitz Type II Heart Block Mobitz II heart block is characterized by a regular PR interval with occasional failure of atrioventricular conduction 7 .

References

1. Duong H, Patel G. Hypothermia. [Updated 2022 Jan 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545239/ 2. Bryan Uy Lo K, Nelson A. Hypothermia and severe first-degree heart block. Cleveland Clinic Journal of Medicine . 2018;85(1):10-11. doi:https://doi.org/10.3949/ccjm.85a.17003 3. Silva JE. Thyroid hormone control of thermogenesis and energy balance. Thyroid. 1995 Dec;5(6):481-92. doi: 10.1089/thy.1995.5.481. PMID: 8808101. 4. Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. 2000 Dec 1;62(11):2485-90. PMID: 11130234. 5. Valenzuela-Vallejo L, Folleco-Ortiz LE, Corredor-Orlandelli D, Aguirre-Ruiz JF, Isaza N, Valenzuela-Rincon A. Myxedema heart disease and non-comatose presentation of myxedema: A case report. SAGE Open Med Case Rep. 2022 Oct 8;10:2050313X221130227. doi: 10.1177/2050313X221130227. PMID: 36225224; PMCID: PMC9549094. 6. Kashou AH, Goyal A, Nguyen T, et al. Atrioventricular Block. [Updated 2023 Feb 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459147/ 7. 1. Fadial T. 2nd Degree AV Block (Mobitz Type II) . https://ddxof.com/ecg-guide-part-ii/2nd-degree-av-block-mobitz-type ii/.

Table 2. Hormone levels by date The patient's cabergoline was stopped briefly in 2019 as indicated by the rise in prolactin. Her levels were not measured upon her 2023 hospital admissions, but it was well documented that she was unable to take her medications and therefore did not have well controlled prolactin levels . Prolactin Level Date 867.2 April 2012 205.9 May 2012 67.4 October 2014 22.1 April 2015 2.6 May 2016 0.6 February 2018 34.2 May 2019 0.7 April 2021 0.9 August 2022

Figure 1. Patient’s Baseline EKG The patient’s heart rhythm at baseline was first degree heart block with associated bradycardia.

Special thank you to Newberry County Memorial Hospital, Dr. Chelsea McCoy, and our patient’s family for allowing us the opportunity to research and report on their patient and loved one.

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2024 Research Recognition Day