3 Aug 2021

2/22/21: Myxedema Coma

PGY2 Matthew Zabrowski presented the case of a 88 year old male with history of ischemic HFrEF (EF 15%), prior CABG and CKD who was found down sitting in chair for unknown down time, minimally responsive.  History limited by patient somnolence.  Patient reports SOB, dyspnea on exertion, bilateral lower extremity edema and recent weight gain.  Per family, patient was previously in his baseline state of health, able to perform all ADLs until 1 week prior.  ROS otherwise was fatigue, dizziness and altered mental status.

Medications: Atorvastatin 40mg qHS, Furosemide 40mg qDay, Mirtazapine 15mg qDay, Bisoprolol 5mg qDay and Aspirin 81mg qDay

Social history: Lives with son, previously able to do all ADLs independently.  Unknown tobacco/alcohol/drug history

Vitals: T 31.3, HR 56, RR 18, BP 93/52, O2 sat 100% on 2L NC

Physical Exam significant for patient being somnolent, A&O x4, withdraws to painful stimuli, mumbling incoherently, normal cardiac exam, pulm with crackles to midlungs bilaterally, moderate increase work of breathing, marked lower extremity edema to mid-thighs bilaterally and multiple bruises noted, peripherally warm to touch.

Labs:
WBC 2.1>Hgb 12.6 (MCV 91.3)/Hct 37.7< Platelets 30
Na 143/K 4.4/Cl 99/HCO3 26/BUN 107/Cr 4.78<Glucose 61
Liver panel: ALP 68>Protein 5.9/Albumin 3.8/AST 76/ALT 31/T Bili 0.9/D Bili 0.7
PT: 17.3, INR 1.44
UA: 30 protein, neg leuks/nitrite
Blood cultures negative, UCx negative, HIV negative, RPR negative
Utox negative, APAP negative, ASA negative, ETOH negative

CXR

EKG

CTH: Negative for intracranial hemorrhage

TSH 101 uIU/mL, FT4 0.23 ng/dL

ACTH 70 pg/mL, Cortisol (Random): 16.5 mcg/dL

Hospital Course: Endocrine was consulted given the thyroid function labs and patient was given Levothyroxine 500mcg IV x1, Hydrocortisone 100mg IV Q8H and admitted to MICU for hemodynamic instability. He was started on broad spectrum antibiotics; however, volume resuscitation was limited by severe volume overload and placed on levophed for pressor support. IV diuresis attempted by patient with minimal urine output. Patient refused hemodialysis initiation and wished to pass naturally over starting dialysis. Patient expired on hospital day 3.

Teaching Points:

  1. Mutifactorial deterioration involving decreased cardiac output, decreased thermal regulation, increased fluid retention and anasarca, hypoxia hypercapnia and eventually AMS/coma.
  2. There is usually preceding by an inciting event – infection, hypothermia, HF exacerbation
  3. Treatment:
    1. IV Levothyroxine 500mcg x1
    2. IV Levothyroxine 50-100mcg qDay
    3. IV Hydrocortisone 100mg Q8H until adrenal insufficiency is ruled out
    4. Fluid resuscitation, intubation, passive rewarming

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