History

Fact Explanation
Previous hypothyroidism. The myxoedema coma or hypothyroid coma is a rare but life threatening complication of hypothyroidism. [1] It is the most severe presentation of profound hypothyroidism and is often fatal in spite of therapy. [2] Some patients may have been treated for hypothyroidism but the crisis has been precipitated by a stress factor (as follows) [2] or some of them may have been ignoring the treatments. Still, some patients present with a crisis for the first time. [3] [4]
A precipitating factor In patients with hypothyroidism, a stress factor can precipitate a myxoedema coma. The known stress factors are infections, burns, hypoglycemia, hypothermia, surgery, trauma and some drugs like Lithium. [1] [2] Treatment defaulters have been reported to present with more severe illness. [5] [6]
A varying degree of altered consciousness The patients with hypothyroid coma can present with any degree of clouded consciousness ranging from mild to a severe psychotic state. [7] [8] Long-standing altered consciousness could be due to untreated hypothyroidism. [6] Some cases may represent stroke syndromes. [9] It's called "myxoedema madness" [10] But the other more common causes of altered consciousness should be evaluated and excluded. i.e. hepatic encephalopathy. [11]
Swelling of ankles Edema of ankles or generalized edema is a common presentation severe hypothyroidism. [1] [10] [12] Laryngeal edema is a potential mortality factor. [13]
Generalized weakness Muscle weakness and fatigue are very common features of hypothyroidism. [9] [14] It can affect various muscle groups. i.e. the diaphragm. [1]
Acute constipation Due to the paralytic ileus in acute severe hypothyroidism. [15] [16] [17] Thyroxine is an essential hormone to maintain the bowel movements. [18]
Fainting They can present with acute myocardial fibrillations, causing syncope. [19]
Sudden death Sudden death has been reported in profound hypothyroidism. [20] The thermoregulation, cardiac dysfunction may be causative factors.
References
  1. WALL CR. Myxedema coma: diagnosis and treatment. Am Fam Physician [online] 2000 Dec 1, 62(11):2485-90 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11130234
  2. WARTOFSKY LEONARD. Myxedema Coma. Endocrinology and Metabolism Clinics of North America [online] 2006 December, 35(4):687-698 [viewed 01 June 2014] Available from: doi:10.1016/j.ecl.2006.09.003
  3. JAMES R., JAMES J., VIJ A. S., VIJ K. K.. Postoperative myxoedema coma. Case Reports [online] December, 2014(feb13 1):bcr2013010066-bcr2013010066 [viewed 01 June 2014] Available from: doi:10.1136/bcr-2013-010066
  4. FRITSCH N., TRAN-VAN D., DARDARE E., GENTILE A., DEROUDILHE G., FONTAINE B.. [The myxoedema coma exists, we met it]. Annales Françaises d'Anesthésie et de Réanimation [online] 2007 September, 26(9):795-798 [viewed 01 June 2014] Available from: doi:10.1016/j.annfar.2007.03.009
  5. DUTTA PINAKI, BHANSALI ANIL, MASOODI SHRIQ, BHADADA SANJAY, SHARMA NAVNEET, RAJPUT RAJESH. Predictors of outcome in myxoedema coma: a study from a tertiary care centre. Critical Care [online] 2008 December [viewed 01 June 2014] Available from: doi:10.1186/cc6211
  6. KANDUKURI RAJEEV C., KHAN MEHNAZ A., SOLTYS STEPHEN M.. Nonadherence to Medication in Hypothyroidism. Prim. Care Companion J. Clin. Psychiatry [online] 2010 May [viewed 01 June 2014] Available from: doi:10.4088/PCC.09m00863gre
  7. LKLOUK . Myxoedema Coma: A Very Rare Presentation of Severe Hypothyroidism. J Med Cases [online] 2013 December [viewed 01 June 2014] Available from: doi:10.4021/jmc1503w
  8. BEYNON JENNIFER, AKHTAR SIMEEN, KEARNEY TARA. Predictors of outcome in myxoedema coma. Array [online] 2008 December [viewed 01 June 2014] Available from: doi:10.1186/cc6218
  9. AHN JI YUN, KWON HYUK-SOOL, AHN HEE CHOL, SOHN YOU DONG. A Case of Myxedema Coma Presenting as a Brain Stem Infarct in a 74-Year-Old Korean Woman. J Korean Med Sci [online] 2010 December [viewed 01 June 2014] Available from: doi:10.3346/jkms.2010.25.9.1394
  10. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396
  11. KOLLMAR R., SCHELLINGER PD., BARDUTZKY J., MEISEL F., SCHWANINGER M.. [Myxedema coma as a rare differential diagnosis of severe consciousness disturbance]. Der Nervenarzt [online] 2002 December, 73(12):1183-1185 [viewed 01 June 2014] Available from: doi:10.1007/s00115-002-1393-1
  12. MATHEW VIVEK, MISGAR RAIZ AHMAD, GHOSH SUJOY, MUKHOPADHYAY PRADIP, ROYCHOWDHURY PRADIP, PANDIT KAUSHIK, MUKHOPADHYAY SATINATH, CHOWDHURY SUBHANKAR. Myxedema Coma: A New Look into an Old Crisis. Journal of Thyroid Research [online] 2011 December, 2011:1-7 [viewed 01 June 2014] Available from: doi:10.4061/2011/493462
  13. FARLING P. A.. Thyroid disease. [online] 2000 July, 85(1):15-28 [viewed 01 June 2014] Available from: doi:10.1093/bja/85.1.15
  14. ALBASHIR S., OLANSKY L., SASIDHAR M.. Progressive muscle weakness: More there than meets the eye. Cleveland Clinic Journal of Medicine [online] December, 78(6):385-391 [viewed 01 June 2014] Available from: doi:10.3949/ccjm.78a.10116
  15. BENNETT WILLIAM E., HEUCKEROTH ROBERT O.. Hypothyroidism Is a Rare Cause of Isolated Constipation. Journal of Pediatric Gastroenterology and Nutrition [online] 2012 February, 54(2):285-287 [viewed 01 June 2014] Available from: doi:10.1097/MPG.0b013e318239714f
  16. BENTLEY RJ, BROWNE RJ. Paralytic ileus and dementia in a case of myxoedema. Postgrad Med J [online] 1969 Dec, 45(530):779-781 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466932
  17. RODRIGO C, GAMAKARANAGE CS, EPA DS, GNANATHASAN A, RAJAPAKSE S. Hypothyroidism causing paralytic ileus and acute kidney injury - case report Thyroid Res [online] :7 [viewed 01 June 2014] Available from: doi:10.1186/1756-6614-4-7
  18. MELISH JS. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition; Chapter 135: Thyroid Disease. [web] [viewed 01 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK241/
  19. MACAULAY MB, SHEPHERD RJ. Syncope in myxoedema due to transient ventricular fibrillation. Postgrad Med J [online] 1971 Jun, 47(548):361-363 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466917
  20. LE MARQUAND HS, HAUSMANN W, HEMSTED EH. Death in Myxoedema Coma Br Med J [online] 1955 Sep 24, 2(4942):773 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1980928

Examination

Fact Explanation
Hypothermia Thyroxine is important in thermoregulation mechanisms. [1] In hypothyroidism, the temperature set point is lowered. [2] Hypothermia is a common feature in severe hypothyroidism. [3] [4] [5] [6] [7] [8]
Skin changes In addition to features of autoimmune diseases like vitiligo [9] [10], chronic dermatosis has been found in higher incidences in thyroid disorders. [9] Myxedema refers to the skin condition caused by increased glycosaminoglycan deposition in the skin. Generalized myxedema is still the classic cutaneous sign of hypothyroidism. The most notable content of these edematous parts are hyaluronic acid. [11] Apart from those, coarse skin, thick skin, yellow coloration, dry skin and reduced sweating have been reported commonly. [11] [12]
Peripheral edema The edema is due to mucopolysaccharide deposition, as mentioned above. As a result the skin does not pit with pressure. [11]
Low blood pressure Hypotension is one of the common symptoms of hypothyroidism. [13] [14] It's also a factor determining the mortality in hypothyroid coma. [15] Postural drop of blood pressure has also been reported in hypothyroid patients. [16]
A neck lump A neck lump confirming a goiter is suggestive of a thyroid disorder. [17] [18] [19]
Features of autoimmune conditions In instances where hypothyroidism is due to autoimmune thyroiditis. [20] [21] [22] The common findings are vitiligo[23], alopecia and rheumatoid features. [24] [25] [26]
Features of tarnsudative fluid collections in body spaces. i.e. Pericardial effusions, pleural effusion and ascites In profound hypothyroidism, there is a fluid transudation in body cavities. [8] [27] [28] To exclude that, examining for dullness in chest and abdomen is necessary.
Altered consciuosness Glasgow coma scale, Mini-Mental score and Mental State Examination are important, given there is adequate time. Patients can have a varying altered consciousness that probably might even progress to acute psychotic state, also known as "myxoedema madness" [29] [30] [31]
References
  1. LITTLE GJ. Thyroid morphology and function and its role in thermoregulation in the newborn southern elephant seal (Mirounga leonina) at Macquarie Island. J Anat [online] 1991 Jun:55-69 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1260313
  2. GORDON CHRISTOPHER J. Behavioral and Autonomic Thermoregulation in the Rat Following Propylthiouracil-induced Hypothyroidism1. Pharmacology Biochemistry and Behavior [online] 1997 September, 58(1):231-236 [viewed 01 June 2014] Available from: doi:10.1016/S0091-3057(97)00014-2
  3. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396
  4. WALL CR. Myxedema coma: diagnosis and treatment. Am Fam Physician [online] 2000 Dec 1, 62(11):2485-90 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11130234
  5. MACDONALD DW. Hypothermic Myxoedema Coma Br Med J [online] 1958 Nov 8, 2(5105):1144-1146 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2026709
  6. ANGEL JH, SASH L. Hypothermic coma in myxoedema. Br Med J [online] 1960 Jun 18, 1(5189):1855-9 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13793663
  7. MALDEN M. Hypothermic coma in myxoedema. Br Med J [online] 1955 Sep 24, 2(4942):764-6 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13250211
  8. MATHEW V, MISGAR RA, GHOSH S, MUKHOPADHYAY P, ROYCHOWDHURY P, PANDIT K, MUKHOPADHYAY S, CHOWDHURY S. Myxedema Coma: A New Look into an Old Crisis J Thyroid Res [online] 2011:493462 [viewed 01 June 2014] Available from: doi:10.4061/2011/493462
  9. ARTANTAş ŞöLEN, GüL ÜLKER, KıLıç ARZU, GüLER SERDAR. Skin findings in thyroid diseases. European Journal of Internal Medicine [online] 2009 March, 20(2):158-161 [viewed 01 June 2014] Available from: doi:10.1016/j.ejim.2007.09.021
  10. DANESHPAZHOOH M, MOSTOFIZADEH G M, BEHJATI J, AKHYANI M, ROBATI RM. Anti-thyroid peroxidase antibody and vitiligo: a controlled study. BMC Dermatol [online] 2006 Mar 10:3 [viewed 01 June 2014] Available from: doi:10.1186/1471-5945-6-3
  11. SAFER JD. Thyroid hormone action on skin Dermatoendocrinol [online] 2011, 3(3):211-215 [viewed 01 June 2014] Available from: doi:10.4161/derm.3.3.17027
  12. BURMAN KENNETH D., MCKINLEY-GRANT LYNN. Dermatologic aspects of thyroid disease. Clinics in Dermatology [online] 2006 July, 24(4):247-255 [viewed 01 June 2014] Available from: doi:10.1016/j.clindermatol.2006.04.010
  13. WARTOFSKY LEONARD. Myxedema Coma. Endocrinology and Metabolism Clinics of North America [online] 2006 December, 35(4):687-698 [viewed 06 June 2014] Available from: doi:10.1016/j.ecl.2006.09.003
  14. MATHEW VIVEK, MISGAR RAIZ AHMAD, GHOSH SUJOY, MUKHOPADHYAY PRADIP, ROYCHOWDHURY PRADIP, PANDIT KAUSHIK, MUKHOPADHYAY SATINATH, CHOWDHURY SUBHANKAR. Myxedema Coma: A New Look into an Old Crisis. Journal of Thyroid Research [online] 2011 December, 2011:1-7 [viewed 06 June 2014] Available from: doi:10.4061/2011/493462
  15. DUTTA PINAKI, BHANSALI ANIL, MASOODI SHRIQ, BHADADA SANJAY, SHARMA NAVNEET, RAJPUT RAJESH. Predictors of outcome in myxoedema coma: a study from a tertiary care centre. Critical Care [online] 2008 December [viewed 06 June 2014] Available from: doi:10.1186/cc6211
  16. LANIER JB, MOTE MB and CLAY EC. Evaluation and Management of Orthostatic Hypotension. Am Fam Physician. [online] 2011 Sep 1;84(5):527-536. [viewed 6th June 2014] Available on http://www.aafp.org/afp/2011/0901/p527.html
  17. HASSAN AI, AREF GH, KASSEM AS. Congenital iodide-induced goitre with hypothyroidism. Arch Dis Child [online] 1968 Dec, 43(232):702-704 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2020155
  18. FIGUEIREDO MD, CARDOSO LC, FERREIRA AC, CAMPOS DV, DA CRUZ DOMINGOS M, CORBO R, NASCIUTTI LE, VAISMAN M, CARVALHO DP. Goiter and hypothyroidism in two siblings due to impaired Ca(+2)/NAD(P)H-dependent H(2)O(2)-generating activity. J Clin Endocrinol Metab [online] 2001 Oct, 86(10):4843-8 [viewed 06 June 2014] Available from: doi:10.1210/jcem.86.10.7934
  19. OZKAN B, OLGUN H, CEVIZ N, POLAT P, TAYSI S, ORBAK Z, KOşAN C. Assessment of goiter prevalence, iodine status and thyroid functions in school-age children of rural Yusufeli district in eastern Turkey. Turk J Pediatr [online] 2004 Jan-Mar, 46(1):16-21 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15074369
  20. CATUREGLI PATRIZIO, KIMURA HIROAKI, ROCCHI ROBERTO, ROSE NOEL R. Autoimmune thyroid diseases. Current Opinion in Rheumatology [online] 2007 January, 19(1):44-48 [viewed 06 June 2014] Available from: doi:10.1097/BOR.0b013e3280113d1a
  21. ZALETEL KATJA, GABERSCEK SIMONA. Hashimoto's Thyroiditis: From Genes to the Disease. Curr Genomics [online] 2011 December, 12(8):576-588 [viewed 06 June 2014] Available from: doi:10.2174/138920211798120763
  22. TOMER YARON, HUBER AMANDA. The etiology of autoimmune thyroid disease: A story of genes and environment. Journal of Autoimmunity [online] 2009 May, 32(3-4):231-239 [viewed 06 June 2014] Available from: doi:10.1016/j.jaut.2009.02.007
  23. UNCU SIBEL, YAYLı SAVAş, BAHADıR SEVGI, ÖKTEN AYşENUR, ALPAY KöKSAL. Relevance of autoimmune thyroiditis in children and adolescents with vitiligo. [online] December, 50(2):175-179 [viewed 06 June 2014] Available from: doi:10.1111/j.1365-4632.2010.04665.x
  24. BURMAN KENNETH D., MCKINLEY-GRANT LYNN. Dermatologic aspects of thyroid disease. Clinics in Dermatology [online] 2006 July, 24(4):247-255 [viewed 06 June 2014] Available from: doi:10.1016/j.clindermatol.2006.04.010
  25. FELDKAMP J. [Autoimmune thyroiditis: diagnosis and treatment]. Dtsch med Wochenschr [online] December, 134(49):2504-2509 [viewed 06 June 2014] Available from: doi:10.1055/s-0029-1243053
  26. PUNZI LEONARDO, BETTERLE CORRADO. Chronic autoimmune thyroiditis and rheumatic manifestations. Joint Bone Spine [online] 2004 July, 71(4):275-283 [viewed 06 June 2014] Available from: doi:10.1016/j.jbspin.2003.06.005
  27. KOLLMAR R., SCHELLINGER PD., BARDUTZKY J., MEISEL F., SCHWANINGER M.. [Myxedema coma as a rare differential diagnosis of severe consciousness disturbance]. Der Nervenarzt [online] 2002 December, 73(12):1183-1185 [viewed 07 June 2014] Available from: doi:10.1007/s00115-002-1393-1
  28. CHINNASAMY ESWARI, RODIN ANDREW. A case of severe hypothyroidism presenting with multi-organ failure. EJEA [online] 2014 March [viewed 07 June 2014] Available from: doi:10.1530/endoabs.34.P416
  29. LKLOUK . Myxoedema Coma: A Very Rare Presentation of Severe Hypothyroidism. J Med Cases [online] 2013 December [viewed 01 June 2014] Available from: doi:10.4021/jmc1503w
  30. BEYNON JENNIFER, AKHTAR SIMEEN, KEARNEY TARA. Predictors of outcome in myxoedema coma. Array [online] 2008 December [viewed 01 June 2014] Available from: doi:10.1186/cc6218
  31. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 01 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396

Differential Diagnoses

Fact Explanation
Acute cardiac failure The acute cardiac failure syndromes are defined as new-onset, gradual, or rapidly worsening HF signs and symptoms that require urgent therapy [1] which makes it an emergency just like myxedema coma and prompt differentiation should be done as to manage either condition. Some patients might present with a history of congestive cardiac failure [2] and in these cases, one should be very careful because it's easier to jump into a wrong conclusion. Cardiac failure usually presents with symptoms of congestion (exertional dyspnea and/or dyspnea at rest, orthopnea, paroxyamal nocturnal dyspnea) and hypoperfusion (chest pain, palpitations). [3] [4] [5] [6] [7]
Hepatic encephalopathy Same risk factors ( as in History segment) can precipitate hepatic encephalopathy. [8] It's important to assess whether there has been a history of liver diseases. Some features are common in both conditions. i.e. ascites, lack of consciousness. [9] [10]
Septic shock Infection can precipitate both a hypothyroid crisis and a septic shock. The clinical features may be very similar and different to identify in emergency setting. [11] [12] [13] [14] Blood investigations for septicemia and thyroid function are keys for diagnosing.
References
  1. COONS J. C., MCGRAW M., MURALI S.. Pharmacotherapy for acute heart failure syndromes. American Journal of Health-System Pharmacy [online] December, 68(1):21-35 [viewed 08 June 2014] Available from: doi:10.2146/ajhp100202
  2. JOSEPH SM, CEDARS AM, EWALD GA, GELTMAN EM, MANN DL. Acute Decompensated Heart Failure: Contemporary Medical Management Tex Heart Inst J [online] 2009, 36(6):510-520 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801958
  3. PATEL RAVI B., SECEMSKY ERIC A.. Clinical Features of Heart Failure and Acute Coronary Syndromes. Clinics in Laboratory Medicine [online] 2014 March, 34(1):15-30 [viewed 08 June 2014] Available from: doi:10.1016/j.cll.2013.11.006
  4. KUMAR A, CANNON CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc [online] 2009 Oct, 84(10):917-38 [viewed 08 June 2014] Available from: doi:10.1016/S0025-6196(11)60509-0
  5. OCHIAI ME, CARDOSO JN, VIEIRA KR, LIMA MV, BRANCALHAO EC, BARRETTO AC. Predictors of low cardiac output in decompensated severe heart failure Clinics (Sao Paulo) [online] 2011 Feb, 66(2):239-244 [viewed 08 June 2014] Available from: doi:10.1590/S1807-59322011000200010
  6. ALLEN LA, O'CONNOR CM. Management of acute decompensated heart failure CMAJ [online] 2007 Mar 13, 176(6):797-805 [viewed 08 June 2014] Available from: doi:10.1503/cmaj.051620
  7. RAMANI GV, UBER PA, MEHRA MR. Chronic Heart Failure: Contemporary Diagnosis and Management Mayo Clin Proc [online] 2010 Feb, 85(2):180-195 [viewed 08 June 2014] Available from: doi:10.4065/mcp.2009.0494
  8. CORDOBA JUAN, VENTURA-COTS MERITXELL, SIMóN-TALERO MACARENA, AMORóS ÀLEX, PAVESI MARCO, VILSTRUP HENDRIK, ANGELI PAOLO, DOMENICALI MARCO, GINéS PERE, BERNARDI MAURO, ARROYO VICENTE. Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute-on-chronic liver failure (ACLF). Journal of Hepatology [online] 2014 February, 60(2):275-281 [viewed 08 June 2014] Available from: doi:10.1016/j.jhep.2013.10.004
  9. PRAKASH R, MULLEN KD. Mechanisms, diagnosis and management of hepatic encephalopathy. Nat Rev Gastroenterol Hepatol [online] 2010 Sep, 7(9):515-25 [viewed 08 June 2014] Available from: doi:10.1038/nrgastro.2010.116
  10. BLEI ANDRES T., CORDOBA JUAN. Hepatic encephalopathy. Am J Gastroenterology [online] 2001 July, 96(7):1968-1976 [viewed 08 June 2014] Available from: doi:10.1111/j.1572-0241.2001.03964.x
  11. KORNELISSE RF, HAZELZET JA, HOP WC, SPANJAARD L, SUUR MH, VAN DER VOORT E, DE GROOT R. Meningococcal septic shock in children: clinical and laboratory features, outcome, and development of a prognostic score. Clin Infect Dis [online] 1997 Sep, 25(3):640-6 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9314453
  12. MARIK PAUL E.. The clinical features of severe community-acquired pneumonia presenting as septic shock. Journal of Critical Care [online] 2000 September, 15(3):85-90 [viewed 08 June 2014] Available from: doi:10.1053/jcrc.2000.16460
  13. COHEN J., GLAUSER M.P.. Septic shock: treatment. The Lancet [online] 1991 September, 338(8769):736-739 [viewed 08 June 2014] Available from: doi:10.1016/0140-6736(91)91453-2
  14. YAMAMOTO YOSHIYUKI, FUJITA KAZUTOSHI, NAKAZAWA SHIGEAKI, HAYASHI TAKUJI, TANIGAWA GO, IMAMURA RYOICHI, HOSOMI MASAHIRO, WADA DAIKI, FUJIMI SATOSHI, YAMAGUCHI SEIJI. Clinical characteristics and risk factors for septic shock in patients receiving emergency drainage for acute pyelonephritis with upper urinary tract calculi. Array [online] 2012 December [viewed 08 June 2014] Available from: doi:10.1186/1471-2490-12-4

Investigations - for Diagnosis

Fact Explanation
Complete blood count Leucocyte count and differential count are important in diagnosing whether there is an infection present. [1] [2]
Free T3 and T4 assay Free thyroid hormones are very low or even undetectable in hypothyroid crisis. [3] [4]
TSH level TSH level can be elevated, and those instances it describes a primary thyroid disorder. [5] [6] [7]
Serum electrolytes Hypothyroidism is a cause for hyponatremia. [8] [9]
Chest x-ray Radiological findings are pericardial and pleural effusions, cardiomegaly and in case of large goiters, tracheal compression and retrosternal extension. [10][11]
12 lead chest ECG Usual recordings are prolonged QT segment, right bundle branch block (RBBB), flat or inverted T wave, QRS prolongation and sinus bradycardia. [12] [13] [14] It reflects cardiac malfunction due to hypothyroidism. [14]
References
  1. SHAPIRO MARTIN F.. Diagnostic Decision: The Complete Blood Count and Leukocyte Differential Count: An Approach to Their Rational Application. Ann Intern Med [online] 1987 January [viewed 08 June 2014] Available from: doi:10.7326/0003-4819-106-1-65
  2. BLUMENREICH MS. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition [web]; Chapter 153, The White Blood Cell and Differential Count. [viewed 08 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK261/
  3. MATHEW V, MISGAR RA, GHOSH S, MUKHOPADHYAY P, ROYCHOWDHURY P, PANDIT K, MUKHOPADHYAY S, CHOWDHURY S. Myxedema Coma: A New Look into an Old Crisis J Thyroid Res [online] 2011:493462 [viewed 08 June 2014] Available from: doi:10.4061/2011/493462
  4. LKLOUK . Myxoedema Coma: A Very Rare Presentation of Severe Hypothyroidism. J Med Cases [online] 2013 December [viewed 08 June 2014] Available from: doi:10.4021/jmc1503w
  5. DUTTA P, BHANSALI A, MASOODI SR, BHADADA S, SHARMA N, RAJPUT R. Predictors of outcome in myxoedema coma: a study from a tertiary care centre Crit Care [online] 2008, 12(1):R1 [viewed 08 June 2014] Available from: doi:10.1186/cc6211
  6. MASOODI SHARIQRASHID, BASHIR MIRIFTIKHAR, AHMAD NADEEM, MIR SHAHNAZAHMAD, WANI ARSHADIQBAL. Lithium toxicity and myxedema crisis in an elderly patient. Indian J Endocr Metab [online] 2013 December [viewed 08 June 2014] Available from: doi:10.4103/2230-8210.123558
  7. IIDA KEIJI, HINO YASUHISA, OHARA TAKESHI, CHIHARA KAZUO. A case of myxedema coma caused by isolated thyrotropin stimulating hormone deficiency and Hashimoto’s thyroiditis. Endocr J [online] 2011 December, 58(2):143-148 [viewed 08 June 2014] Available from: doi:10.1507/endocrj.K10E-329
  8. KARGILI A, TURGUT FH, KARAKURT F, KASAPOGLU B, KANBAY M, AKCAY A. A forgotten but important risk factor for severe hyponatremia: myxedema coma Clinics (Sao Paulo) [online] 2010 Apr, 65(4):447-448 [viewed 08 June 2014] Available from: doi:10.1590/S1807-59322010000400015
  9. SCHUTT-AINE JC. Hypothyroid Myxedema and Hyponatremia in an Eight-Year-Old Child: A Case Report J Natl Med Assoc [online] 1980 Jul, 72(7):705-708 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552507
  10. GUPTA Y, AMMINI AC. Vitiligo, hypothyroidism and cardiomyopathy Indian J Endocrinol Metab [online] 2012, 16(3):463-465 [viewed 08 June 2014] Available from: doi:10.4103/2230-8210.95715
  11. FARLING P. A.. Thyroid disease. [online] 2000 July, 85(1):15-28 [viewed 08 June 2014] Available from: doi:10.1093/bja/85.1.15
  12. ASAMI TADASHI, SUZUKI HIROSHI, YAZAKI SATOSHI, SATO SEIICHI, UCHIYAMA MAKOTO. Effects of Thyroid Hormone Deficiency on Electrocardiogram Findings of Congenitally Hypothyroid Neonates. Thyroid [online] 2001 August, 11(8):765-768 [viewed 08 June 2014] Available from: doi:10.1089/10507250152484600
  13. ADAMS CRAWFORD W.. Electrocardiographic Changes in Hypothyroidism. CHEST [online] 1964 July [viewed 08 June 2014] Available from: doi:10.1378/chest.46.1.87
  14. ZHANG YIYI, POST WENDY S., CHENG ALAN, BLASCO-COLMENARES ELENA, TOMASELLI GORDON F., GUALLAR ELISEO, HERNANDEZ ADRIAN V.. Thyroid Hormones and Electrocardiographic Parameters: Findings from the Third National Health and Nutrition Examination Survey. PLoS ONE [online] 2013 April [viewed 08 June 2014] Available from: doi:10.1371/journal.pone.0059489

Investigations - Followup

Fact Explanation
T3 , T4 hormone assays and TSH (Thyorid profile) To assess the response to treatments, and look out for complications. [1] [2]
References
  1. LIEWENDAHL K., HELENIUS T., LAMBERG B.-A., MAHONEN H., WAGAR G.. Free thyroxine, free triiodothyronine, and thyrotropin concentrations in hypothyroid and thyroid carcinoma patients receiving thyroxine therapy. European Journal of Endocrinology [online] 1987 November, 116(3):418-424 [viewed 08 June 2014] Available from: doi:10.1530/acta.0.1160418
  2. FADEYEV VV, MORGUNOVA TB, SYTCH JP, MELNICHENKO GA. TSH and thyroid hormones concentrations in patients with hypothyroidism receiving replacement therapy with L-thyroxine alone or in combination with L-triiodothyronine. Hormones (Athens) [online] 2005 Apr-Jun, 4(2):101-7 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16613812

Management - General Measures

Fact Explanation
Maintaining the airway and securing the breathing It's the utmost priority since the patients either may present with respiratory failure or progress into it. [1] [2] [3] [4] Artificial airway management i.e. intubation may be essential in some cases but may be difficult. [2]
Fluid management A difficult decision, fluid supplementation is necessary in hypotension, and fluid restriction is necessary in hyponatremia. [1] [5] Fluid management should depend on the severity of each complication. In patients who have hyponatremia should be given hypertonic saline (i.e. 3%) and when hypotension is more prominet, 5%dextrose should be given. [1]
Warming Managing the hypothermia by external warming, but the accompanying vasodilatation may precipitate hypotension. [1] Active re-warming can be life saving. [6] [7] [8]
Continuous monitoring Respiratory and heart rates, systolic BP, temperature, urine output, conscious level, oxygen saturation, capillary blood sugar and volume status should be monitored frequently, the frequency depending on the severity of the presentation. [9] [10] [11]
Patient education The patient should be de-briefed about the crisis he/she had to undergo, and how to be adherent to the medication to avoid future episodes. The drug interactions, how to look for drug adverse effects also should be added, with how to store medicine, when and how to take them and when to get the next thyroid profile done. [12] [13] [14]
References
  1. MATHEW V, MISGAR RA, GHOSH S, MUKHOPADHYAY P, ROYCHOWDHURY P, PANDIT K, MUKHOPADHYAY S, CHOWDHURY S. Myxedema Coma: A New Look into an Old Crisis J Thyroid Res [online] 2011:493462 [viewed 08 June 2014] Available from: doi:10.4061/2011/493462
  2. LEE CHRISTOPHER H., WIRA CHARLES R.. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. The American Journal of Emergency Medicine [online] 2009 October, 27(8):1021.e1-1021.e2 [viewed 08 June 2014] Available from: doi:10.1016/j.ajem.2008.12.027
  3. BUCKLE RM, GARFIELD J. Myxedema coma complicated by respiratory failure. Proc R Soc Med [online] 1969 Jan, 62(1):38 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2279074
  4. STINSON JM, CUMMINGS CL. Acute Respiratory Failure and Hypothyroidism J Natl Med Assoc [online] 1980 Jan, 72(1):53-54 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2537396
  5. VERBALIS JOSEPH G., GOLDSMITH STEPHEN R., GREENBERG ARTHUR, SCHRIER ROBERT W., STERNS RICHARD H.. Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations. The American Journal of Medicine [online] 2007 November, 120(11):S1-S21 [viewed 08 June 2014] Available from: doi:10.1016/j.amjmed.2007.09.001
  6. WARTOFSKY LEONARD. Myxedema Coma. Endocrinology and Metabolism Clinics of North America [online] 2006 December, 35(4):687-698 [viewed 09 June 2014] Available from: doi:10.1016/j.ecl.2006.09.003
  7. WALL CR. Myxedema Coma: Diagnosis and Treatment. Am Fam Physician. [online] 2000 Dec 1;62(11):2485-2490 [viewed 09 June 2014] Available from: http://www.aafp.org/afp/2000/1201/p2485.html
  8. LKLOUK . Myxoedema Coma: A Very Rare Presentation of Severe Hypothyroidism. J Med Cases [online] 2013 December [viewed 09 June 2014] Available from: doi:10.4021/jmc1503w
  9. KYRIACOS UNA, JELSMA JENNIFER, JAMES MICHAEL, JORDAN SUE, SALLUH JORGE I. F.. Monitoring Vital Signs: Development of a Modified Early Warning Scoring (Mews) System for General Wards in a Developing Country. PLoS ONE [online] 2014 January [viewed 09 June 2014] Available from: doi:10.1371/journal.pone.0087073
  10. SIMMONS SUSAN. Myxedema coma. Nursing [online] 2010 June [viewed 09 June 2014] Available from: doi:10.1097/01.NURSE.0000376307.36712.6a
  11. ASIIMWE STEPHEN B., OKELLO SAMSON, MOORE CHRISTOPHER C., SALLUH JORGE I. F.. Frequency of Vital Signs Monitoring and its Association with Mortality among Adults with Severe Sepsis Admitted to a General Medical Ward in Uganda. PLoS ONE [online] 2014 February [viewed 09 June 2014] Available from: doi:10.1371/journal.pone.0089879
  12. CRILLY M, ESMAIL A. Randomised controlled trial of a hypothyroid educational booklet to improve thyroxine adherence Br J Gen Pract [online] 2005 May 1, 55(514):362-368 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463159
  13. HAYNES RB, ACKLOO E, SAHOTA N, MCDONALD HP, YAO X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev [online] 2008 Apr 16:CD000011 [viewed 09 June 2014] Available from: doi:10.1002/14651858.CD000011.pub3
  14. VAIDYA B., PEARCE S. H S. Management of hypothyroidism in adults. BMJ [online] 2008 July, 337(jul28 1):a801-a801 [viewed 09 June 2014] Available from: doi:10.1136/bmj.a801

Management - Specific Treatments

Fact Explanation
Thyroid hormone supplementation T3 (triiodothyronine) is the active hormone in the body. [1] Since in severe illnesses there can be a reduced conversion of T4 to T3, it's not very effective to give T4 (thyroxine) as the treatment option in emergency setting. [1] [2] T3 when given in intraveous form has a shorter half-life, so needs to give in loading dose followed by regular infusions. [3] Triiodothyronine may not be widely available in the ER setting, and also because of it's potent action can increase the incidence of myocardial infarction or heart failure thus mortality. Some reports show adequate recovery with oral T3. Intravenous T4 is also recognized as a form of management. Once the patient is stabilized, conversion to oral T4 can be achieved. [1] [2] [4] [5] [6] [7]
Intravenous steroids Hypoadrenalism can be masked by hypothyroidism in a crisis. When thyroid hormones are replaced, hypoadrenalism becomes obvious. In emergency settings, to prevent associated mortality, intravenous setroids, preferably hydrocortisone is given. [1] [4] [5]
Maintenance with oral thyroxine Daily thyroxine supplementation with oral tablets. The dose is to be stated small and gradually increased according to the TSH response as checked monthly. Once TSH reaches the desired level, yearly follow-up with thyroid profile is desirable. [8] [9] [10] [11]
Management of the precipitating factor i.e. Antibiotics for the infection. To remove the risk factor. [4]
References
  1. MATHEW V, MISGAR RA, GHOSH S, MUKHOPADHYAY P, ROYCHOWDHURY P, PANDIT K, MUKHOPADHYAY S, CHOWDHURY S. Myxedema Coma: A New Look into an Old Crisis J Thyroid Res [online] 2011:493462 [viewed 08 June 2014] Available from: doi:10.4061/2011/493462
  2. WARTOFSKY LEONARD, BURMAN KENNETH D.. Alterations in Thyroid Function in Patients with Systemic Illness: The “Euthyroid Sick Syndrome”*. Endocrine Reviews [online] 1982 January, 3(2):164-217 [viewed 09 June 2014] Available from: doi:10.1210/edrv-3-2-164
  3. HAYS MARGUERITE T., MCGUIRE ROBERT A.. Distribution of Subcutaneous Thyroxine, Triiodothyronine, and Albumin in Man: Comparison with Intravenous Administration Using a Kinetic Model*. The Journal of Clinical Endocrinology & Metabolism [online] 1980 November, 51(5):1112-1117 [viewed 09 June 2014] Available from: doi:10.1210/jcem-51-5-1112
  4. WALL CR. Myxedema Coma: Diagnosis and Treatment. Am Fam Physician. [online] 2000 Dec 1;62(11):2485-2490 [viewed 09 June 2014] Available from: http://www.aafp.org/afp/2000/1201/p2485.html
  5. LKLOUK . Myxoedema Coma: A Very Rare Presentation of Severe Hypothyroidism. J Med Cases [online] 2013 December [viewed 09 June 2014] Available from: doi:10.4021/jmc1503w
  6. HYLANDER B., ROSENQVIST U.. Treatment of myxoedema coma factors associated with fatal outcome. European Journal of Endocrinology [online] 1985 January, 108(1):65-71 [viewed 09 June 2014] Available from: doi:10.1530/acta.0.1080065
  7. BADUNI N, SINHA SK, SANWAL MK. Perioperative management of a patient with myxedema coma and septicemic shock Indian J Crit Care Med [online] 2012, 16(4):228-230 [viewed 09 June 2014] Available from: doi:10.4103/0972-5229.106510
  8. KEHOE WA JR, DONG BJ, GREENSPAN FS. Maintenance Requirements of L-Thyroxine in the Treatment of Hypothyroidism West J Med [online] 1984 Jun, 140(6):907-909 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1011127
  9. BRAVERMAN LE, VAGENAKIS A, DOWNS P, FOSTER AE, STERLING K, INGBAR SH. Effects of Replacement Doses of Sodium-L-Thyroxine on the Peripheral Metabolism of Thyroxine and Triiodothyronine in Man J Clin Invest [online] 1973 May, 52(5):1010-1017 [viewed 09 June 2014] Available from: doi:10.1172/JCI107265
  10. KABADI UDAYA M.. Optimal Daily Levothyroxine Dose in Primary Hypothyroidism. Arch Intern Med [online] 1989 October [viewed 09 June 2014] Available from: doi:10.1001/archinte.1989.00390100045012
  11. LEBOFF MERYL S., KAPLAN MICHAEL M., SILVA J.ENRIQUE, LARSEN P.REED. Bioavailability of thyroid hormones from oral replacement preparations. Metabolism [online] 1982 September, 31(9):900-905 [viewed 09 June 2014] Available from: doi:10.1016/0026-0495(82)90179-2