myxedema coma; hypothyroid coma
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Etiology
- systemic illness superimposed on previously undiagnosed hypothyroidism
Epidemiology
- rare
Pathology
Clinical manifestations
- poorly responsive (lethargy), unreponsive, coma
- hypotension, shock
- bradycardia
- hypothermia
- non-pitting peripheral edema, thickened skin[3]
Laboratory
- serum TSH: very high
- serum thyroxine: very low; free thyroxine: very low
- serum glucose: hypoglycemia
- serum cortisol
- serum sodium: hyponatremia
Diagnostic procedures
Radiology
- chest X-ray: rule out pneumonia
Complications
- aspiration pneumonia associated with hypoventilation & reduced level of consciousness
- cardiac arrhythmias associated with high-dose thyroxine
- mortality 20-15%[1]
Management
- medical emergency
- IV hydrocortisone & levothyroxine for initial therapy (MKSAP20)[1]
- MKSAP20 seemingly retracts earlier recommendation[1]
- but then states intravenous hydrocortisone should be empirically initiated before thyroid hormone administration to treat possible concomitant adrenal insufficiency ???
- why is intravenous hydrocortisone not the correct initial therapy ???
- previously, start IV hydrocortisone 100 mg every 8 hours[1]
- unless serum cortisol > 18 ug/dL[1]
- start prior to administration of thyroxine to treat possible comorbid adrenal insufficiency[1]
- IV hydrocortisone & levothyroxine for initial therapy (MKSAP20)[1]
- 50-100 ug thyroxine IV every 6 hours for 24 hours
- monitor EKG
- ventilatory support as needed
- vasopressors as needed
- treat hypothermia[1]
- warmed intravenous fluids[1]
- treat precipitating systemic illness
More general terms
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. PMID: https://pubmed.ncbi.nlm.nih.gov/17712058
- ↑ 3.0 3.1 3.2 Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ Hampton J. Thyroid gland disorder emergencies: thyroid storm and myxedema coma. AACN Adv Crit Care. 2013 Jul-Sep;24(3):325-32. Review. PMID: https://pubmed.ncbi.nlm.nih.gov/23880755
- ↑ Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am. 2012 Mar;96(2):385-403. Review. PMID: https://pubmed.ncbi.nlm.nih.gov/22443982
- ↑ Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. PMID: https://pubmed.ncbi.nlm.nih.gov/28142035 Free PMC Article
- ↑ Kim J Myxedema N Engl J Med 2015; 372:764. February 19, 2015 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/25693016 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMicm1403210