Myxedema Coma with Case

00:01 In this case, a 78 year old woman presents to the emergency department unresponsive.

00:07 Per her family, she has become progressively more lethargic and confused.

00:12 She lives alone and has not taken her medications for some time.

00:16 She had a thyroidectomy 4 years ago for a multinodular goiter.

00:20 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.

00:34 Her BMI is 28.

00:36 She is arousable to painful stimuli, skin color is cool and dry and she is diffusely edematous.

00:44 Her deep tendon reflexes display delayed relaxation phase.

00:50 Her serum sodium and glucose are both low.

00:53 What is the most likely diagnosis in this patient? This is an elderly woman who manifest with progressive lethargy, confusion and then ultimately, unresponsiveness.

01:05 She is known to be hypothyroid and has not taken her medications.

01:11 On exam, she is hypotensive, bradycardic and has a low respiratory rate.

01:16 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 and hypoglycemia.

01:31 Putting this all together, this most likely fits with a condition known as myxedema coma.

01:37 This presentation is also very similar to hypoadrenalism or low cortisol.

01:43 Myxedema coma, although a rare condition is an extreme presentation of hypothyroidism and can lead to life-threatening secondary systemic decompensation.

01:53 Mortality rates are as high as 20-25%.

01:57 Precipitating factors include myocardial infarction, significant infections, strokes, trauma, gastrointestinal bleeding, metabolic derangements and cold exposure.

02:11 Myxedema coma is much more common in elderly women and patients with a history of hypothyroidism.

02:18 How does one treat myxedema coma? First of all, because of the similarities in presentation, always rule out adrenal insufficiency.

02:27 This can be done by checking the cortisol level.

02:30 While the cortisol level is pending, always provide an empiric dose of hydrocortisone because hypoadrenalism is a significant condition and should be treated early.

02:41 Supportive care and mechanical ventilation with vasopressors may be required as well as the patient is unresponsive or comatose.

02:50 Also find the precipitating event.

02:52 Send off labs, do other investigations to try to make that diagnosis.

02:57 Restoration of the euthyroid state should be achieved by giving thyroid hormone to the patient.

03:04 And then finally, warmed intravenous fluids and a space blanket will help with the hypothermia.