RESUMO
BACKGROUND: Myxedema coma is a rare, but life-threatening endocrinological emergency. Myxedema is characterized by altered mental status, and is accompanied by hypotension, bradycardia, hypothermia, bradypnea, hyporeflexia, hyponatremia, and hypoglycemia, all stemming from reduced metabolism due to severe hypothyroidism. Additionally, patients may exhibit signs of low cardiac output, edema in the extremities, peripheral circulatory disturbances, shock, and the development of pericardial and pleural effusions, ultimately leading to confusion and coma. We present a successfully treated case of severe myxedema coma with recurrent pericardial effusion and hypotensive shock. This case is characterized by an unusual clinical presentation and required a distinct treatment strategy highlighting its exceptional rarity. CASE: A 2-year-old boy with Down syndrome presented with recurrent pericardial effusion attributed to medication non-adherence. The critically-ill patient, experiencing a severe cardiogenic shock required mechanical ventilation and inotropic infusions in the pediatric intensive care unit. Elevated thyroid stimulating hormone (TSH), and low free T4 (fT4) and free T3 (fT3) levels prompted consideration of myxedema coma. Upon reviewing the patient's medical history, it was ascertained that he had an ongoing diagnosis of primary hypothyroidism, and exhibited non-adherence to the prescribed treatment regimen and failed to attend scheduled outpatient clinic appointments for follow-up assessments. The treatment plan, devised by the pediatric endocrinology team, included the peroral administration of L-thyroxine (L-T4) at a dose of 50 micrograms per day. After beginning regular oral L-T4 treatment, a gradual improvement in the patient's condition was observed. Notably, by the 15th day of oral therapy, the patient had made a full recovery. Contrary to the recommended intravenous treatment for myxedema coma, this patient was successfully treated with oral levothyroxine, due to the unavailability of the parenteral form in Türkiye. CONCLUSIONS: This case report presents an instance of non-adherence to L-T4 therapy, which subsequently progressed to severe myxedema coma. Changes in neurologic status and hemodynamic instability in a patient with a history of hypothyroidism should raise the concern of nonadherence and, though rare, myxedema coma should be in the differential diagnosis.
Assuntos
Coma , Síndrome de Down , Mixedema , Derrame Pericárdico , Tiroxina , Humanos , Masculino , Mixedema/tratamento farmacológico , Mixedema/diagnóstico , Mixedema/complicações , Tiroxina/uso terapêutico , Tiroxina/administração & dosagem , Coma/etiologia , Coma/tratamento farmacológico , Pré-Escolar , Derrame Pericárdico/tratamento farmacológico , Derrame Pericárdico/etiologia , Derrame Pericárdico/diagnóstico , Síndrome de Down/complicações , Adesão à Medicação , Hipotireoidismo/tratamento farmacológico , Hipotireoidismo/complicaçõesRESUMO
BACKGROUND: Graves' disease is the autoimmune activation of the thyroid gland causing diffuse enlargement and hyperfunction of the gland. Manifestations of Graves' disease are multisystemic and include thyroid orbitopathy; pretibial myxedema, also referred to as thyroid dermopathy; and thyroid acropachy, described as a severe form of thyroid dermopathy. Our paper focuses on an atypical case of thyroid dermopathy. CASE PRESENTATION: An 11-year-old Saudi male presented with a prominent diffuse goiter and exophthalmos. Investigations were consistent with a diagnosis of Graves' disease. The physical exam showed diffuse, non-pitting swelling of the ankle and penis, mimicking a lymphatic malformation. Further, multiple nodules were found on the hands and feet. Treatment of the nodules with cautery resulted in more severe nodules. CONCLUSION: This report describes rare presentations of thyroid dermopathy mimicking lymphatic malformation. The Koebner phenomenon can explain this patient's atypical presentations. Intralesional injections of triamcinolone and total thyroidectomy showed clear improvement.
Assuntos
Exoftalmia , Doença de Graves , Mixedema , Dermatopatias , Humanos , Masculino , Criança , Doença de Graves/complicações , Doença de Graves/diagnóstico , Mixedema/diagnóstico , Mixedema/etiologiaRESUMO
We report two cases of myxoedema coma that presented to the acute medical take with severe bradycardia. These patients were initially misdiagnosed as bradyarrhythmia of primary cardiac origin. They were then diverted to the cardiology service at another district general hospital (DGH) for admissions. Both cases were subsequently diagnosed with myxoedema coma having screened thyroid function tests on arrival at the cardiology unit. Despite being treated for myxoedema coma, both patients unfortunately succumbed to the disease and later died in the hospital. These cases highlight that clinical suspicion and recognition of myxoedema coma remain significant challenges in a developed world despite readily available and highly sensitive thyroid hormone assays.
Assuntos
Bradicardia , Coma , Mixedema , Humanos , Bradicardia/etiologia , Bradicardia/diagnóstico , Mixedema/diagnóstico , Coma/etiologia , Evolução Fatal , Feminino , Masculino , Idoso , Erros de Diagnóstico , Testes de Função Tireóidea , Diagnóstico Diferencial , Idoso de 80 Anos ou mais , Pessoa de Meia-IdadeRESUMO
This case report describes tofacitinib treatment for 2 patients with pretibial myxedema.
Assuntos
Mixedema , Piperidinas , Pirimidinas , Humanos , Dermatoses da Perna/tratamento farmacológico , Dermatoses da Perna/diagnóstico , Dermatoses da Perna/patologia , Mixedema/tratamento farmacológico , Mixedema/diagnóstico , Piperidinas/uso terapêutico , Piperidinas/administração & dosagem , Inibidores de Proteínas Quinases/uso terapêutico , Inibidores de Proteínas Quinases/administração & dosagem , Pirimidinas/uso terapêutico , Pirimidinas/administração & dosagem , Pirróis/administração & dosagem , Pirróis/uso terapêutico , Resultado do TratamentoRESUMO
Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.
Assuntos
Hipotireoidismo , Mixedema , Adulto , Humanos , Estados Unidos/epidemiologia , Pacientes Internados , Mixedema/complicações , Mixedema/terapia , Estudos Retrospectivos , Coma/complicações , Coma/diagnóstico , Hipotireoidismo/complicações , Hipotireoidismo/epidemiologia , Tempo de InternaçãoRESUMO
A 70-year-old female had a history of thyroid surgery for benign nodules and Graves' disease. Following mRNA COVID-19 vaccination, she presented Graves' orbitopathy and pretibial myxedema. Symptoms of thyroid eye disease and thyroid dermopathy improved after 500-mg methylprednisolone infusions.
Assuntos
COVID-19 , Doença de Graves , Oftalmopatia de Graves , Mixedema , Feminino , Humanos , Idoso , Vacinas contra COVID-19 , Doença de Graves/diagnóstico , RNA MensageiroRESUMO
Graves' disease is the most common cause of thyrotoxicosis and is characterized by ophthalmopathy with proptosis, chemosis, or conjunctival injection; pretibial myxedema; and thyroid acropachy. It is an autoimmune disease that can be genetic or influenced by coexisting environmental factors such as exposure to anticancer drugs, including immune checkpoint inhibitors. The incidence rate of breast cancer is increasing due to rising awareness of risk factors and screening for breast cancer, and the mortality rate is decreasing due to recent advances in cancer treatment. However, there are side effects that are attributed to these treatment modalities, manifesting in various forms in breast cancer survivors, which are reflected in the patient in this case study.
Assuntos
Neoplasias da Mama , Doença de Graves , Mixedema , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/complicações , Trastuzumab/efeitos adversos , Anticorpos Monoclonais , Doença de Graves/diagnóstico , Doença de Graves/tratamento farmacológico , Doença de Graves/complicações , Mixedema/complicações , Mixedema/terapiaRESUMO
BACKGROUND Myxedema coma is a rare, life-threatening condition caused by a severe form of hypothyroidism. The dangerously low levels of circulating thyroid hormone can lead to progressive mental status changes and numerous organ dysfunctions, including serious cardiac abnormalities. CASE REPORT We present a case of a 59-year-old woman who presented with altered mental status and fall who was originally thought to have a cerebrovascular accident but was later diagnosed with myxedema coma, after multiple cardiac arrests. It was discovered that the patient had not been taking any of her medications for the last several weeks, after her primary care provider retired from practice. Initial laboratory evaluation was significant for a TSH level of 159.419 mIU/L and an undetectable free T4 level. Complications of the myxedema coma resulted in QTC interval prolongation, causing torsades de pointes and sustained polymorphic ventricular tachycardia, requiring cardioversion. CONCLUSIONS This case demonstrates the importance of early detection and treatment of myxedema coma, as it can cause life-threatening cardiac arrhythmias. It also emphasizes the need to ensure proper medication adherence in patients with chronic medical conditions, as non-compliance can result in dire consequences.
Assuntos
Hipotireoidismo , Mixedema , Taquicardia Ventricular , Torsades de Pointes , Feminino , Humanos , Pessoa de Meia-Idade , Mixedema/diagnóstico , Mixedema/tratamento farmacológico , Coma/diagnóstico , Coma/etiologia , Hipotireoidismo/complicações , Torsades de Pointes/complicações , Adesão à MedicaçãoRESUMO
INTRODUCTION: Pretibial myxedema is a rare manifestation of Graves' disease, and pseudotumoral forms may be confused with lower limb lymphedema. OBSERVATIONS: We reported 3 cases of pretibial myxedema in 2 women and 1 man, aged 72, 66, and 49 years, treated for Graves' disease 3, 25 and 32 years previously. Two patients were active smokers. Lymphedema diagnosis of the lower limbs was suspected in the presence of bilateral pseudotumoral lesions of the feet, toes and ankles and the presence of a Stemmer's sign (skin thickening at the base of the 2nd toe, pathognomonic of lymphedema). Lymphoscintigraphy in one case was normal, not confirming lymphedema. CONCLUSION: Pretibial pseudotumoral myxedema is a differential diagnosis of lower limb lymphedema. This diagnosis is confirmed by questioning the patient about preexisting Graves' disease, the underlying etiology, to decide the appropriate treatment and to encourage cessation of smoking, which is a risk factor for pretibial myxedema.
Assuntos
Doença de Graves , Dermatoses da Perna , Mixedema , Masculino , Humanos , Feminino , Mixedema/diagnóstico , Mixedema/etiologia , Mixedema/patologia , Diagnóstico Diferencial , Doença de Graves/complicações , Doença de Graves/diagnóstico , Extremidade Inferior/patologia , Dedos do Pé/patologia , Dermatoses da Perna/diagnóstico , Dermatoses da Perna/etiologia , Dermatoses da Perna/patologiaRESUMO
BACKGROUND Pericardial effusions are considered to be present when accumulated fluid within the pericardial sac exceeds the small amount that is normally present, causing impairment in the diastolic filling of the right heart. This case demonstrates an uncommon presentation of a large pericardial effusion by showing its relationship to myxedema in a patient with untreated hypothyroidism. CASE REPORT A 42-year-old man with a past medical history of hypertension, diabetes mellitus, and opioid abuse presented to the emergency department due to altered mental status, for which he received Narcan without resolution of symptoms. Computed tomography (CT) of the brain was without any acute intracranial abnormalities to explain the patient's altered mental status. CT chest reported a pericardial effusion, with a subsequent transthoracic echocardiogram (TTE) showing a moderate-to-large circumferential effusion without right atrial/ventricular collapse and no cardiac tamponade physiology. On further investigation, he was found to have severe hypothyroidism with elevated thyroid peroxidase antibodies. Endocrinology was consulted to start IV levothyroxine and liothyronine to treat autoimmune Hashimoto's thyroiditis. Subsequent TTE after starting hypothyroidism treatment showed an ejection fraction (EF) of 45-50% with mildly reduced left ventricular systolic function and moderate-to-large pericardial effusion, with no evidence of tamponade physiology. After treatment of hypothyroidism, the thyroid panel, EF, and pericardial effusion improved significantly. CONCLUSIONS This case illustrates the potential for suffering a large pericardial effusion secondary to generalized myxedema in a patient with severe hypothyroidism from undiagnosed Hashimoto's thyroiditis. It is important to recognize this condition for appropriate therapy and prevention of worsening cardiac conditions.
Assuntos
Doença de Hashimoto , Hipotireoidismo , Mixedema , Derrame Pericárdico , Masculino , Humanos , Adulto , Mixedema/diagnóstico , Mixedema/etiologia , Derrame Pericárdico/etiologia , Hipotireoidismo/complicações , Hipotireoidismo/diagnóstico , Doença de Hashimoto/complicações , Doença de Hashimoto/diagnóstico , Tiroxina/uso terapêuticoRESUMO
Graves' disease (GD) is one of the urgent problems of modern endocrinology, characterized by a high frequency, polysystemic damage to the body, a steadily progressive course, diagnostic difficulties, a high degree of disability and often resistance to therapy. The manifestations of the disease include: thyrotoxicosis syndrome with impaired lipid and carbohydrate metabolism, and activation of multiple organ pathology in the form of thyroid eye disease (TED), pretibial myxedema, cardiovascular insufficiency, acropathy, lesions of the nervous, osteoarticular system, and other lesions. The development of multiple organ pathology can have a different sequence, different time intervals and different degrees of severity. Any developments in the direction of clarifying the etiopathogenetic, clinical diagnostic and treatment-rehabilitation measures are of undoubted significance. We present a clinical case of GD, TED and pretibial myxedema, in which an integrated approach was tested in the tactics of treating pretibial myxedema (a combination of pulse therapy with prednisolone and FREMS-therapy), as a result of which positive results were obtained within a short time.
Assuntos
Doença de Graves , Oftalmopatia de Graves , Mixedema , Humanos , Doença de Graves/complicações , Doença de Graves/tratamento farmacológico , Oftalmopatia de Graves/complicações , Oftalmopatia de Graves/tratamento farmacológico , Mixedema/complicações , Mixedema/tratamento farmacológico , Pacientes , Prednisolona/uso terapêuticoRESUMO
Myxedema coma is a rare and life-threatening endocrine emergency characterized by abnormalities in multiple organ systems. A 32-year-old woman with prolonged undiagnosed severe hypothyroidism was referred to our hospital owing to lower abdominal pain and menopause for more than 3 months. She underwent exploratory laparotomy and induced abortion under general anesthesia, and developed severe hypoxemia after extubation. She was diagnosed with myxedema coma, and was subsequently discharged with a good prognosis following treatment. This case suggests that myxedema coma should be considered a potential etiology of peri-operative hypoxemia. The findings in this case emphasize the importance of anesthesiologists' comprehensive understanding of myxedema coma. Prompt diagnosis followed by treatment is essential to reduce the mortality rate associated with this condition.
Assuntos
Coma , Mixedema , Feminino , Gravidez , Humanos , Adulto , Coma/etiologia , Extubação/efeitos adversos , Mixedema/complicações , Anestesia Geral , Hipóxia/etiologiaRESUMO
Myxedema is a rare, cutaneous complication of autoimmune thyroid diseases that most often affects the anterior shins. Herein, we report a patient with a history of Graves disease and Hashimoto thyroiditis who presented with boggy, alopecic patches associated with scalp pruritus. Punch biopsies from these lesions showed increased interstitial mucin in the reticular dermis, consistent with localized myxedema. This report showcases a rare presentation of localized myxedema of the scalp, highlighting the diverse cutaneous manifestations of autoimmune thyroid diseases.
Assuntos
Doença de Graves , Doença de Hashimoto , Mixedema , Humanos , Couro Cabeludo , Mixedema/complicações , Alopecia , Biópsia , Doença de Graves/complicações , Doença de Hashimoto/complicaçõesRESUMO
Pretibial myxedema, more generally thyroid dermopathy, results from mucopolysaccharide accumulation in the dermis, typically between the knee and dorsal foot. Thyroid dermopathy presents in Graves disease, but can occur in Hashimoto thyroiditis, primary hypothyroidism, and euthyroid patients. Treatment of thyroid eye disease with teprotumumab is established in the literature, with few case reports also showing improvement in pretibial myxedema. Reported is a 76-year-old man with thyroid eye disease and pretibial myxedema treated with teprotumumab; improvement was demonstrated in both conditions. He developed "muffled" hearing as an adverse effect, a complication not widely published in the dermatology literature. At 18 months post-treatment, his symptoms are stable without recurrence, but hypoacusis persists. Given the long-term efficacy and side-effects, dermatologists should recognize the potential benefits and risks of using teprotumumab for thyroid dermopathy. A baseline audiogram may be considered prior to therapy. Additionally, longitudinal data is needed to document the benefits and risks of this novel therapy.
Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Oftalmopatia de Graves , Dermatoses da Perna , Mixedema , Ototoxicidade , Masculino , Humanos , Idoso , Dermatoses da Perna/complicações , Ototoxicidade/complicações , Oftalmopatia de Graves/complicações , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/complicaçõesRESUMO
Not required for Clinical Vignette.
Assuntos
Mixedema , Tiroxina , Humanos , Tiroxina/uso terapêutico , Mixedema/complicações , Mixedema/tratamento farmacológico , Coma/induzido quimicamente , Coma/tratamento farmacológicoRESUMO
Background: More than 40 years have passed since the introduction of newborn screening (NBS) for congenital hypothyroidism (CH), and many early diagnosed patients have reached adulthood. Their thyroid morphology and function have been little studied. This cross-sectional, observational study was conducted to characterize the thyroid morphology and function of adult CH patients diagnosed in the framework of NBS for CH. Methods: A total of 103 adult CH patients born after 1979 were enrolled at Ito Hospital, Tokyo, Japan, and were classified into Goiter, Normal gland, and Dysgenesis groups based on ultrasonographic findings. For 60 patients, genetic analysis was performed. Thyroid function test results and the proportion of patients with thyroid nodules were compared among the three groups and between 56 female CH patients and 168 non-CH women matched for thyrotropin levels. Results: A significantly low serum free triiodothyronine/free thyroxine ratio (0.22) was observed in the Dysgenesis group. Thyroid nodules were detected in 14.3% (8/56) of female CH patients, more frequently than in non-CH women. Thyroid nodules were detected most frequently in the Goiter group (71%, 10/14). Genetic defects were identified in 89% (8/9) of patients belonging to the Goiter group, including thyroglobulin defect (33%, 3/9), thyroid peroxidase defect (33%, 3/9), and dual oxidase 2 defect (22%, 2/9). Conclusions: Our results suggest that adults with thyroid dysgenesis on levothyroxine replacement therapy have relative triiodothyronine deficiency. Most adults with goitrous CH have genetic dyshormonogenesis. They are at high risk of developing thyroid nodules. Our findings support the current guideline recommendation that CH patients with dyshormonogenesis should undergo periodic thyroid ultrasonography.
Assuntos
Hipotireoidismo Congênito , Bócio , Mixedema , Nódulo da Glândula Tireoide , Tireoidite Autoimune , Recém-Nascido , Humanos , Adulto , Feminino , Hipotireoidismo Congênito/diagnóstico , Hipotireoidismo Congênito/tratamento farmacológico , Tri-Iodotironina , Estudos Transversais , Tiroxina/uso terapêuticoRESUMO
OBJECTIVE: Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking. DESIGN AND METHODS: All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients. RESULTS: A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine. CONCLUSION: Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.