Virginia Research Day 2021

Medical Resident Research Case Reports

08 Myxedema Coma

Michael Rinker, DO; Kimberly Bird, MD Corresponding author: michael.rinker@lpnt.net

SOVAH Health Family Medicine Residency Program

Context: Myxedema coma is a medical emergency and is defined as hypothyroidism leading to Altered mental status (AMS) and hypothermia. Case report: A 66-year-old AA male presented to the ER with AMS. In the ER he was found to be hypothermic with a temperature of 91 degrees F. TSH was found to be elevated at 15.70 with a low normal FT4 at 0.82. He was admitted to the medical floor with AMS, concern for bacteremia, and medication noncompliance with his Levothyroxine. He became bradycardic into the 20s and 30s and hypotensive within the first 24 hours of admission and was transferred to the ICU for vasopressors. Past Medical & Surgical History (Hx): HTN, Dementia, hypothyroidism, seizure disorder, medication noncompliance, bipolar disorder, and NIDDM. Social Hx: Lives with girlfriend, smokes cigarettes and marijuana.

Family History: Significant for HTN and DM. Review of Systems: Unable to obtain due to AMS Pertinent Physical Exam Findings: Bradycardic, he was alert and oriented to person only and had generalized weakness on exam. Vital Signs: BP 108/67, HR 52 trended down to 29, Temp 91 degrees F, SP02 97% on 2L NC. Diagnostic Studies: Head CT and chest x-ray showed no acute findings, EKG showed atrial fib with rate of 39 and no ST changes. TSH initially 15.70 and trended down to 3.54. FT4 0.82, FT3 low at 0.8, Total T3 37, Total cortisol 12.1. Treatment: Levothyroxine 50mcg daily was restarted and stress dose steroids (Solu-cortef) 100mg Q8H IV were initiated. Bair hugger was used for re-warming. Dopamine and isoprel were given due to hypotension and bradycardia and were weaned off over several days.

Diagnosis: Myxedema coma. Comments: This patient presented with classic symptoms of myxedema coma including hypothyroidism, hypotension, hypothermia, and bradycardia. Myxedema coma is uncommon in modern times due to the early diagnosis and treatment of hypothyroidism. The patients likely cause of myxedema coma was medication noncompliance. After several days of stress dose steroids and levothyroxine, his temperature and heart rate normalized, and he was transferred to the general medical floor for further non-urgent treatment and discharge planning. Laboratory evaluation of patients with suspected myxedema coma include TSH (elevated), FT4 (low), Cortisol (to rule out adrenal causes, and FT3 (low). Treatment includes glucocorticoids until adrenal insufficiency has been excluded, thyroid hormone replacement, and symptomatic treatment.

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