Myxoedema Coma Masquerading as Acute Stroke
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Early recognition of myxoedema coma is essential, however the chance of misdiagnosis remains high. Key management consists of rapid thyroid hormone replacement, supportive measures and the concomitant management of triggers such as infection.

A 79-year-old woman presented to the Emergency Department with slurred speech and arm weakness in the context of deteriorating mobility, cognition and oral intake for 3 months. She was not taking regular medications and her only medical history consisted of radioactive iodine treatment for hyperthyroidism in 1990 and subsequent iatrogenic hypothyroidism. The patient had chosen to stop taking levothyroxine in 2010.

On arrival she had a temperature of 33.3°C, a heart rate of 45 bpm and a blood pressure of 170/99 mmHg. Her oxygen saturations were 90% on room air. Her GCS was 9/15. She had dry flaky skin, coarse hair, frontal balding, globally depressed reflexes, a hoarse voice and peripheral oedema. There was no palpable goitre. A CT scan of the head demonstrated focal right cerebellar calcification of questionable clinical significance, but otherwise no acute pathology to explain her stupor.

Blood tests demonstrated Na+ 127 mmol/l, CRP 19 mg/l, creatine kinase (CK) 586 IU/l, TSH 51 mU/l, T4 2.6 pmol/l, T3 <0.8 pmol/l and cortisol 1,001 nmol/l. Re-warming was initiated alongside the administration of broad-spectrum intravenous antibiotics for possible aspiration pneumonia. The patient was later commenced on combination treatment of T4 25 µg via the nasogastric (NG) route and 10 µg IV T3 replacement three times a day (due to concerns about poor absorption). This was initially combined with regular hydrocortisone as adrenal insufficiency often coexists.
Although no organ support was required, the patient was taken to the critical care unit for close monitoring as treatment risks arrhythmia and myocardial infarction.

Unfortunately, the patient passed away after a 28-day admission, which was complicated by recurrent hospital-acquired pneumonias, non-ST-elevation myocardial infarction (NSTEMI), a subsequent per rectum bleed, and raised CK secondary to thyroid myositis.

Conclusively, Myxoedema coma can be difficult to recognise, but early treatment is imperative. Management is three-fold and consists of rapid thyroid hormone replacement, supportive measures and the treatment of coexisting problems, most importantly infection. This is most effectively done in a critical care environment, at least in the acute phase.

Source: https://www.ejcrim.com/index.php/EJCRIM/article/view/1563/2067
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