Virginia Research Day 2021

Myxedema Coma Michael Rinker, DO., Kimberly Bird, MD Sovah Health Family Medicine Residency Program, Danville, VA

Abstract # RC-8

Hospital Course: Patient was initially admitted to the general medical floor and home medications were restarted and a Bair Hugger was placed to correct hypothermia. On hospital day 1, patient became hypotensive with MAP 49 and bradycardic with HR in 20s-30s. He was treated with atropine and started on a dopamine drip and transferred to the ICU for further management. He was treated with IV hydrocortisone and heart rate/hypotention was treated with Isuprel and dopamine, which were eventually weaned over several days. Heart rate, blood pressure, mental status, and temperature eventually improved, and patient was transferred to the general medical floor on hospital day 5. Physical Exam: General: Alert and oriented to only person. Well appearing. Eyes: Anicteric sclera. Conjunctiva non-injected. Neck: Supple without masses. No thyromegaly noted. Trachea midline. Cards: bradycardic without murmur, rub, or gallop. Resp: CTA B/L without wheezes. Skin: warm and dry, no diaphoresis. Abdomen: non-tender to palpation, normal bowel sounds, no guarding or rebound. Extremities: no peripheral edema. MSK: generalized weakness in all 4 extremities. Laboratory EKG initially showed sinus bradycardia with 1 st degree AV block with repeat EKG showing atrial fibrillation 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. Radiology : Head CT and chest x-ray showed no acute findings.

Discussion: 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. This patient’s likely cause of myxedema coma was medication noncompliance. After several days of stress dose steroids, vasopressors, Bair Hugger, and levothyroxine, his temperature, mental status, and heart rate improved. He was eventually transferred to the general medical floor for 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. Conclusion: Myxedema coma is a potentially life-threatening condition that should be considered in any patient presenting with altered mental status, bradycardia, and hypothermia.

Background : Myxedema coma is a medical emergency and is defined as hypothyroidism leading to Altered mental status and hypothermia. Chief Complaint & History: 66-year-old African American Male presents to the ER with altered mental status. He was found to be hypothermic with temperature of 91 degrees F. He was admitted with acute metabolic encephalopathy and hypothermia with concern for medication noncompliance. He was recently admitted 2 weeks earlier with acute metabolic encephalopathy, urinary tract infection, bradycardia, and hypothermia. During that admission it was noted his TSH was elevated at 9.26. He was eventually discharged home and restarted on home levothyroxine. Past Medical History: Seizure disorder, non- insulin dependent diabetes melitis, traumatic brain injury, bipolar disorder, hypertension, medication noncompliance, dementia, and hypothyroidism. Review of Systems: Unable to obtain due to altered mental status. Social History: . Lives with his girlfriend. He smokes 1/4 th packs per day of cigarettes and occasional marijuana use. No alcohol use. Family History: Significant for HTN and DM in both his Mother and Father.

References: Ross, D. (2019). Myxedema coma. In D. Cooper & J Mulder (Ed.), UpToDate. Retrieved 10/28/2020, from https://www.uptodate.com/contents/myxedema-coma SOVAH Health Danville. Electronic medical record.

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