A Case of Myxedema Crisis

An Endocrine Emergency

Dr.R.Ganesan

PG in Internal Medicine

History

C/O loss of consciousness -5 daysC/O cough and expectoration-1 monthNo c/o fever convulsion vomiting/head ache weakness of UL &LL facial asymmetry sedative/narcotics abuse

• Not a k/c of DM/SHT/CAD

• Known case of hypothyroidism past 15 years not on treatment past 2 years

• Non smoker/alcoholic

Vitals

• BP:IIO/80mmHg

• PR:60/min

• RR:18/min

Examination

• Unconscious• Temp:97F• Dry scally skin• B/L non pitting pedal edema• Pallor• Macroglossia• Bed sore

CNS

• GCS: E-2 M-4 V-3=9/15

• Pupils size 4mm reacting to light

• OCR present no occular bobbing/dipping• DTR: absent

• Plantar: extensor

• No neck stiffness

• Fundus examination normal

• CVS: S1,S2+,no murmur

• RS:NVBS,b/l crepts+

• Abdomen: Soft, no organomegaly

Investigations

CBC• Hb-7.6g%• TC-10200cells/cmm• DC:P35%,L60%,E5%• ESR:15/38mm• Platelet:1.8lak/cmm

• PS for anaemia Dimorphic anaemia

• Reticulocytic count-2%

• RFT:Urea-24mg%,creat-0.9mg%

• RBS-77mg%

• UrineR/E-normal

Lipid profile

• T .CHO:163

• TGL:230

• LDL:95

• HDL:36

• VLDL:32

• ECG:sinus bradycardia rate 58/min, old AWMI, low voltage complex

• CXR:Normal• ECHO:Mild concentric LV ,

Hypokinesia of IVS,LV anterior wall , LV apex,mild LV systolic dysfunction, noPE

• CT-brain:Normal

TFT

• FT3:17.2 ng/dl [80-200]

• FT4:1.39 micg/dl [4.6-12]

• TSH:68.8 mIU/ml [0.27-4.2]

• LFT: WNL

• HIV-negative

Electrolytes

Na 106 116 125 129

K 4 3.6 3.9 4.1

• Sputum c/s-klebsiella grown in culture sensitive to Amikacin,Ciprofloxcin

• Urine c/s-no organism grown

• Blood culture-no organism grown

Diagnosis

• Myxedema crisis

• Euvolumic hyponatremia

• CAD-old AWMI

• Anaemia

• Lower respiratory tract infection

Treatment

• Passive warming• Thyroxin:0.1mg 5 tab stat, 2 tab/day• Hydrocortisone:50mg tid• 3% Normal Saline• Antianginal drugs• Atarvostatin:10mg 2 HS• IV Antibiotics• Packed cell transfusion

Myxedema Crisis

• Common disorder of older age group

• Womens 8% >Men 2%

• Mortality rate>50% without treatment, >25% even with treatment

Neurologic manifestation

• Myxedema coma is misnomer absence of coma does not exclude the diagnosis

• Lethargy,stupor,delirium may be manifestation of myxedema coma

• The exact mechanism causing changes in mental status not known

Cardiovascular Manifestations

• Bradycardia / decreased contractility

• Decreased stroke volume

• Increased systemic vascular resistance

• Increased capillary permeability

• Pericardial effusion

Renal Manifestation

• Decreased GFR

• Decreased Na reabsorption

• Impair free water excretion• Hyponatremia

GI Manifestions

• Decreased intestinal motility

• Gastric atony

• Megacolon

• Paralytic ileus

• Malabsorption

Pulmonary Manifestation

• Respiratory muscle dysfunction

• Depressed ventilatory drive

• Obstructive sleep apnea syndrome

• Pleural effusion

Precipitating factors

• Infections

• Cold environment

• Trauma/Burns• Cerebrovascular accident

• GI bleed

• Drugs:sedatives,anesthetics,narcotics, diuretics, lithium,amiodarone, rifampin

Thyroxin Replacement

• GI-absorption is very low-IV therapy is mandatory

• T4 or T4+T3 or T3• Because deiodinase conversion of T4

to active T3 is reduced T3 administration may be advisable

• T3 immediate action and short t1/2 more likely to cause arrhythmias

• IV loading dose 500micg T4 followed by 50-100micg/day until patient is able to take medication by oral

• Elderly pt and pt with CAD full doseT4 may worsen myocardial ischemia

• Yong pt with low cardiovascular risk T310-20micg every 8-12 hours

Stress Steroid Replacement

• Adrenal insufficiency associated with hypothyroidism

• Thyroxin precipitate adrenal crisis• Hydrocortisone 5-10mg/hr

Warming

• Active warming: rapid and external rewarming are contraindicated

• Passive warming:using ordinary blankets and warm room

Infections

• Overt or occult infection precipitate myxedema crisis

• Fever and elevated WBC count are usually absent

• Pan culture and initiate empiric broad spectrum antibiotics

Predictors of survival

• Hypotension and bradycardia at presentation

• Need of mechanical ventilation• Hypothermia not responding to

treatment

• Sepsis

• Lower Glasgow Coma Scale

Complications

• Adrenal crisis: if not treated with concomitantly with stress dose of IV corticosteroids

• Myocardial infarction:may be precipitated by IV thyroxin

Follow-up

• Primary hypothyroidism:Assess TSH level every 6 weeks and adjust T4 dose

• Secondary hypothyroidism:Monitor FT4 level,measurement of TSH not usefull

THANK U