The diagnosis of myxedema coma is a clinical diagnosis based upon history and physical. It is a lifethreatening complication with a mortality rate of 2560 percent and tends to affect older adults. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. To develop diagnostic criteria for myxedema coma mc, a decompensated state of extreme hypothyroidism with a high mortality rate if untreated, in order to facilitate its early recognition and treatment. Myxedema coma discharge care what you need to know. Myxedema coma occurs when thyroid hormone levels are not treated or controlled.
Clinical characteristics and outcomes of myxedema coma. In the last 7 years numerous reports 115 have appeared in the british medical literature dealing with myxedema, shock, and coma. The question is how to restore the low serum and tissue thyroid hormone concentrations to. We present a patient with typical symptoms of myxedema coma, but found to be pancytopenic, with sustained response to levothyroxine and blood transfusion for anemia. Clinical signs in addition to the more typical clinical signs of. It can also develop when someone stops taking their thyroid medication. Hypothyroidism is a clinical syndrome in which the deficiency or absence of thyroid hormone slows bodily metabolic processes.
Clinical thyroidology for the public volume 10 issue 4 pdf file, 1. Myxedema coma is an extremely rare syndrome of severe hypothyroidism characterized by profound weakness, hypothermia, bradycardia, and a diminished level of consciousness, which can rapidly progress to stupor and then coma chastain et al, 1982. Myxedema can occur in the lower leg pretibial myxedema and behind the eyes exophthalmos. Thyroid hormones may be measured every 1 to 2 days. It is a rare disorder, with only approximately 300 cases described in the literature typically elderly females have longstanding, undiagnosed hypothyroidism more than 90% of cases occur during winter months 5. Myxedema coma, unlike what the name suggests, does not require a comatose state for diagnosis. Finora is now affiliated with the veterinary emergency clinic and referral centre, toronto, ontario, canada.
The condition is diagnosed from a combination of abnormal thyroid function, physical examination findings of severe hypothyroidism, and altered mental status. Wilson and bedell studied26patientswithmyxedema, sortingthem into groups according to the presence of obesity and underlying pulmonary disease. Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. Thyroidectomy scar in patients with altered mental status, suggests myxedema coma as a potential cause a swedish study, by mourtzinis et al, found the rates of hypothyroidism and hyperthyroidism in patients with atrial fibrillation to be 5. Signs and symptoms are many and are often insidious.
Myxedema coma is a rare but severe complication of myxedema. Hematologic consequences of myxedema coma include mild leukopenia and anemia, rarely pancytopenia. Severe cases, requiring hospitalization can exhibit signs of hypothermia, hypoglycemia, hypotension, respiratory depression, and coma. Myxedema coma is a rare clinical condition that represents severe hypothyroidism decompensation usually occurs in patient with longstanding. Myxedema coma can be triggered by not taking medicine to treat hypothyroidism. Drugs, such as phenothiazines, amiodarone, lithium, and tranquilizers, and prolonged iodide use. However, despite the ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a challenge. It is classically characterized by thickened, nonpitting edema of the skin diffusely associated with severe chronic hypothyroidism. Myxedema coma is a severe and lifethreatening form of decompensated hypothyroidism with an underlying precipitating factor. There are some triggering factors like exposition to low temperatures, infections, irregular performance of hormone replacement therapy in patients with hypothyroidism, adverse reactions of medications like amiodarone, lithium, anesthetics, hypnotics, sedatives or tranquilizers. Untreated or unrecognized hypothyroidism may progress to severe decompensated hypothyroidism or myxedema coma.
Myxedema coma, a rare yet fatal disease, can present clinicians with a diagnostic dilemma because patients pre sent with altered consciousness. Myxedema coma is a state of decompensated hypothyroidism. Myxoedema coma is a rare and lifethreatening illness the outcome of which has not been robustly studied in large numbers, partly due to its. Pdf raionale myxedema coma mc is extremely rare but lethal in pediatric patients with hypothyroidism leading to altered mental status and. Case report, diagnosis, emergency, myxedema coma, renal failure. Myxedema coma was first reported by ord in 1879 in london. Myxedema coma induced by ingestion of raw bok choy to the editor. Myxedema coma is a rare lifethreatening clinical condition in patients with longstanding severe untreated hypothyroidism, in whom adaptive mechanisms fail to maintain homeostasis. The diagnosis of myxedema coma was made based on the patients clinical presentation and a score of 65 on the diagnostic scoring system published in 2014 by popoveniuc et al. Some symptoms of myxedema coma include fatigue, lethargy, depression, dry skin, and weight gain.
Myxedema and coma severe hypothyroidism endotext ncbi. Myxedema coma is a severe form of hypothyroidism low thyroid function. Diagnostic scoring system for myxedema coma thermoregulatory dysfunction temperature of c points 9535 0 89. The construct of myxedema coma sets clinicians up for diagnostic failure. Most patients, however, are not comatose, and the entity rather represents a form of very severe, decompensated hypothyroidism. A person may have lab values identical to a normal hypothyroid state, but a stressful event such as an infection, myocardial infarction or stroke precipitates the myxedema coma state, usually in the elderly. Myxedema coma is a very rare endocrine emergency as a result of a very low synthesis of thyroid hormone due to some precipitating factors such as infections, hypothermia, heart failure, stroke, trauma, digestive bleeding, poor compliance of prescribed thyroid. The term myxedema coma is a misnomer, and myxedema crisis may be an apt term as quite a few patients are obtunded, rather than frankly comatose. Nevertheless, although the need to treat these patients with thyroid hormone is so patently obvious, the regimen by which to conduct this treatment remains somewhat controversial.
Our goal is to inform the global em community with timely and high yield content about what providers like you are seeing and doing everyday in your local ed. Thyroid hormones help control body temperature, heart rate, growth, and weight. The mortality rates may be as high as 2560% even with best possible treatment 15. The diagnosis of myxedema coma is made when the three key diagnostic features of myxedema coma are present, which include altered mental status, hypothermia or absence of fever and a precipitating event such as cold exposure, infection, drugs.
Symptoms can manifest in all organ systems and range in severity based on the degree of hormone deficiency. Most patients, however, are not comatose, and the entity rather represents a form. Decompansated hypothyroidsm myxedema coma is a loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood hypothyroidism. The frequencies of characteristics associated with mc were assessed retrospectively in patients from our institutions in order to derive a semiquantitative. If you have severe hypothyroidism, then any of the following can contribute to myxedema coma. The therapeutic endpoints of levothyroxine therapy in patients with myxedema coma should be improved mental status, improved cardiac function, and improved pulmonary function. Myxedema coma is the most severe manifestation of hypothyroidism. Myxedema coma, caused by severe lack of thyroid hormone, is characterized by.
It is a medical emergency and associated with increased risk of death. The aim of this study was to identify the factors that may increase the risk of death for the patients hospitalized for myxedema coma. It can be brought about by removal of the thyroid for any cause, by a cessation of function of the gland, or simply by glandular atrophy. Prompt recognition and treatment are mandatory for a successful outcome. Hypothyroidism risk factors for death in patients with myxedema coma ono y et al. Pdf myxedema crisis is a severe life threatening form of decompensated hypothyroidism which is.
Myxedema coma, the extreme manifestation of hypothyroidism, is an uncommon but potentially lethal condition. Myxedema and coma severe hypothyroidism updated 2018 apr 25. In spite of ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a clinical challenge. It is unclear what the optimal levels for serum tsh and thyroid hormones should be in this population.
Myxedema coma is defined as severe hypothyroidism resulting in a decompensated metabolic state and mental status change. It is considered a lifethreatening complication of hypothyroidism and represents the far more serious side of the spectrum of thyroid disease. Myxedema coma, occasionally called myxedema crisis, is a rare lifethreatening clinical condition that represents severe hypothyroidism with physiological decompensation. Decompensated hypothyroidism may be conceptualized as hypothyroidism causing organ failure. Myxedema coma in the elderly american board of family. Diagnosis of myxedema coma complicated by renal failure. Predictors of outcome in myxoedema coma critical care full text. Myxedema is a result of undiagnosed or untreated severe hypothyroidism. Low intracellular t3 leads to cardiogenic shock, respiratory depression, hypothermia and coma. Uptodate, electronic clinical resource tool for physicians and patients that provides information on adult primary care and internal medicine, allergy and immunology, cardiovascular medicine, emergency medicine, endocrinology and diabetes, family medicine, gastroenterology and hepatology, hematology, infectious diseases, nephrology and hypertension, neurology, obstetrics, gynecology, and women. An 88yearold chinese woman was brought to the emergency department by her family, who reported that she had been lethargic. Correspondence from the new england journal of medicine myxedema coma induced by ingestion of raw bok choy. Myxedema coma is the ultimate stage of severe longstanding hypothyroidism. Myxedema coma induced by ingestion of raw bok choy nejm.
The typical characteristics of myxedema coma, including bradycardia, hypotension, and hypothermia, were absent in this case. Mild myxedema coma usually is treated by a general practitioner or internist while moderate to severe myxedema coma is treated and managed by an endocrinologist. Myxedema is known to occur in various forms of hypothyroidism, and also in graves disease. Myxedema, physiological reaction to lack of sufficient thyroid hormone hypothyroidism in the adult. Myxedema coma is a rare and potentially fatal manifestation of severe hypothyroidism that can be successfully treated using intravenous levothyroxine. A survey of these reports indicates that 19 out of 25 patients died in spite of vigorous treatment with corticosteroids, vasopressors, thyroid compounds, antibiotics, warming, and electrolyte and fluid correction. The condition is diagnosed from a combination of abnormal thyroid function, physical examination findings of severe hypothyroidism. Hypothyroidism and myxedema coma clinical presentation. Hypothyroidism is a frequently diagnosed and simply treated disease. Analysis of a national inpatient database in japan. The term myxedema coma is a misnomer, and myxedema crisis may be an apt term as quite a few patients are obtunded, rather than.
Myxedema coma or myxedema crisis is a lifethreatening complication of hypothyroidism. Myxedema coma definition, symptoms, causes, treatment. An 88yearold chinese woman was brought to the emergency. A diagnostic scoring system for myxedema coma johns. Myxedematous coma is a syndrome that results from the intense reduction of the thyroid hormone synthesis. Hypothyroidism and myxedema coma differential diagnoses. An atypical case of myxedema coma with concomitant. It is a medical emergency with a high mortality rate. One of the hallmarks of graves disease is pretibial myxedema, myxedema of the. Decompensated hypothyroidism myxedema coma emcrit project. Hypothyroidism is common, with an extreme manifestation of myxedema coma if untreated.
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