In this case, a 78 year old woman presents
to the emergency department unresponsive.
Per her family, she has become
progressively more lethargic and confused.
She lives alone and has not taken
her medications for some time.
She had a thyroidectomy 4 years
ago for a multinodular goiter.
On exam, we find a temperature of 36
degrees celsius, a blood pressure of 77/40
and a heart rate of 50 beats per minute accompanied
by a respiratory rate of 8 breaths per minute.
Her BMI is 28.
She is arousable to painful stimuli, skin color is
cool and dry and she is diffusely edematous.
Her deep tendon reflexes display
delayed relaxation phase.
Her serum sodium and glucose are both low.
What is the most likely
diagnosis in this patient?
This is an elderly woman who
manifest with progressive lethargy,
confusion and then ultimately,
She is known to be hypothyroid and
has not taken her medications.
On exam, she is hypotensive, bradycardic
and has a low respiratory rate.
Her skin is cool, dry and
edematous and her neuro exam
is notable for delayed relaxation
phase of the deep tendon refelxes
Her labs are real hyponatremia
Putting this all together, this most likely
fits with a condition known as myxedema coma.
This presentation is also very similar
to hypoadrenalism or low cortisol.
Myxedema coma, although a rare condition is
an extreme presentation of hypothyroidism
and can lead to life-threatening
secondary systemic decompensation.
Mortality rates are as high as 20-25%.
Precipitating factors include myocardial infarction,
significant infections, strokes, trauma,
gastrointestinal bleeding, metabolic
derangements and cold exposure.
Myxedema coma is much more common in elderly women
and patients with a history of hypothyroidism.
How does one treat myxedema coma?
First of all, because of the similarities in
presentation, always rule out adrenal insufficiency.
This can be done by checking
the cortisol level.
While the cortisol level is pending, always
provide an empiric dose of hydrocortisone
because hypoadrenalism is a significant
condition and should be treated early.
Supportive care and mechanical ventilation
with vasopressors may be required as well
as the patient is unresponsive or comatose.
Also find the precipitating event.
Send off labs, do other investigations
to try to make that diagnosis.
Restoration of the euthyroid state should be
achieved by giving thyroid hormone to the patient.
And then finally, warmed intravenous fluids and
a space blanket will help with the hypothermia.