(431) Cracking the Code: Insights From a Myxedema Coma Case

Introduction: Myxedema coma is a severe manifestation of hypothyroidism characterized by decreased mental status, hypothermia, and multi-organ dysfunction. Though rare due to advances in early diagnosis, it remains a medical emergency with high mortality. Timely recognition and treatment are crucial and should be based on clinical suspicion rather than waiting for lab results. Clues include thyroidectomy history or radioiodine therapy. Symptoms often progress from thyroid dysfunction to lethargy and coma.

Description: An 81-year-old female with HFrEF, CKD, and atrial fibrillation presented with altered mental status. Over weeks, she had become increasingly withdrawn, lethargic, and refused home medications. EMS found her hypoxic (83% on room air), unresponsive, and hypoglycemic (47 mg/dL). In the ED, she required intubation for acute hypoxic respiratory failure. Initial vital signs showed a temperature of 33.9°C, blood pressure of 90/50 mmHg, heart rate at 60 bpm, and elevated creatinine (8 mg/dL). Labs revealed significant metabolic disturbances including hyponatremia, hypoglycemia, and elevated creatinine. TSH was 11.19, free T4 was 1.0, and free T3 was undetectable. Imaging showed severe cardiomegaly and negative infectious workup. Using the diagnostic scoring system by Popoveniuc et al. (2014), the patient scored 120 points: hypothermia (10), coma (30), anorexia/abdominal pain/constipation (5), cardiomegaly (15), hypotension (20), hyponatremia (10), hypoglycemia (10), hypoxemia (10), and decreased GFR (10). Bradycardia did not apply due to a paced heart rate.

The patient initially improved with thyroid hormone replacement and glucocorticoids, reducing Levophed requirements and allowing extubation. However, she experienced a PEA arrest a day later and did not achieve ROSC.

Discussion: This case highlights the importance of considering myxedema coma in patients with unexplained multiorgan failure despite inconclusive thyroid tests. The diagnostic scoring system proved vital in guiding management. Key features include decreased mental status, hypothermia, hypotension, hyponatremia, and hypoglycemia. Prompt recognition and treatment are essential to improve outcomes. This case supports the use of comprehensive diagnostic criteria in clinical practice for accurate diagnosis and timely intervention.