Successful Treatment of Myxedema Coma: A Case Report

Donnie Lumban Gaol, Achnes Pangaribuan, Kurniyanto, Budi Setiawan, Hildebrand Hanoch Victor, Yunus Tanggo

Departement of Internal Medicine, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta

Background
Myxedema coma is a severe life threatening form of decompensated hypothyroidism. Infections and discontinuation of thyroid supplements are the major precipitating factors. The mortality rates may be as high as 2560% even with best possible treatment.

Case Report

Patient 48-year-old man, had history of thyroidectomy , 9 years ago with unknown of thyroid hormone therapy.

He was admitted with feeling fatigue, muscle weakness, headache, nausea, and decrease mobility since one week ago.

Three days after admission patient was found with confusion & lethargy without seizures.

Case report Complete blood test shows acute infection, uncontrolled glycemic. Chest x-ray figured pneumonia. Abdominal Ultrasonography revealed right pleura effusion, massive ascites and a normal-sized liver and spleen. Three days after admission patient was found with confusion & lethargy without seizures. Brain CT revealed normal.
We assessed patient with myxedema coma and treated with levothyroxine (thyrax) 100 mcg twice daily orally without laboratory result. From investigation revealed severe hypothyroidism with TSHs 11.1117 uIU/ml and free T4 < 0.4 ng/dl. After following the administration of thyroid replacement hormones for hypothyroid, her clinical condition improved gradually. Patient was given levothyroxine (thyrax) 100 mcg once daily as a maintenance therapy.

Imaging Examination

USG : Right pleura effusion, massive ascites

Imaging Examination

Chest x-ray : consolidation and thickening of right pleura

CT Brain revealed Normal Scan

LABORATORIUM RESULT
Erythrocyte sedimentation rate Haemoglobin Leukocytes Erythrocytes Hematocrites Trombocytes MCV MCH MCHC Albumin Globulin AST ALT Fasting plasma glucose HbA1 Total cholesterol Triglycerides HDL LDL Ureum Creatinin Sodium Potasium Chloride TSHs FT4 Result 75 (H) 12.2 (L) 12.5 (H) 3.95 (L) 34.5 (L) 659 (H) 87.4 30.9 35.4 3.51 3.73 16 8 270 (H) 14 (H) 156.5 83 30 99 20 0.91 144 4.7 91 11.1117 < 0.40 Normal Range <10 mm/hr 14-16 g/dL 5-10 103/L 4.5-5.5 106/mL 40-48 % 150-400 x 103/ L 82-92 /fL 27-31 pg 32-36 % 3.7-5.2 g/dL 2.9-3.1 g/dL 10-34 U/L 9-43 U/L 70-110 mg/dL 4.5-6.3 % 150-250 mg/dL 40-160 mg/dL 35-55 mg/dL <155 mg/dL 15-45 mg/dL 0.7-1.1 mg/dL 136-145 mmol/L 3.5-5.1 mmol/L 99-111 mmol/L 0.35-4.94 IU/ml 0.7-1.48 ng/dL

Discussion
Infections and history of thyroidectomy are the precipitating factors. Once clinicaly suspected to myxedema coma, treatment can be lifesaving and should be start promptly in anticipation of confirmation of the diagnosis by laboratory test.
PATIENT
History of Thyroidectomy

Pleuropnemonia
Clinical Presentations

treat as myxedema coma without laboratory confirmation (do not delay treatment)

clinically myxedema coma

Discussion
Our Patient
TSHs FT4 11.1117 IU/ml < 0.40 ng/dL

Discussion
Thyroid hormone therapy is the backbone of treatment of patients with myxedema coma and most authorities therefore recommend use of Thyroxine (T4) alone. Oral administration of T4 has proved to be equally effective compare with intravenous T4. The mechanism of ascites fluid formation in patients with myxedema is unclear. There are two main hypotheses. The first is that low levels of circulating thyroid hormones cause increased extravasation of plasma proteins because of abnormal capillary permeability and the lack of a compensatory increase in lymph flow and protein return rate. The second hypothesis is that hyaluronic acid accumulates in the skin and produces edema by a direct hygroscopic effect. However, hyaluronic acid has only been found in minute quantities in patients with myxedema ascites: not large enough to exert a direct hygroscopic effect. However, it could interact with albumin to form complexes that prevent the lymphatic drainage of extravasated albumin.

Conclussion Early recognition and prompt treatment with thyroid hormone replacement is crucial in the management of myxedema coma due to potentially fatal condition