Hypothyroidism and Myxedema Coma

Hypothyroidism is a clinical syndrome in which the deficiency or absence of thyroid hormone slows bodily metabolic processes. Symptoms can manifest in all organ systems and range in severity based on the degree of hormone deficiency. The disease typically progresses over months to years but can occur quickly following cessation of thyroid replacement medication or surgical removal of the thyroid gland.

The term myxedema refers to the thickened, nonpitting edematous changes to the soft tissues of patients in a markedly hypothyroid state. Myxedema coma, a rare, life-threatening condition, occurs late in the progression of hypothyroidism. The condition is seen typically in elderly women and is often precipitated by infection, medication, environmental exposure, or other metabolic-related stresses. Because rapid confirmatory laboratory tests are often unavailable, the diagnosis may be made on clinical grounds with treatment started promptly. ^[1]

Treatment of myxedema coma requires potentially toxic doses of thyroid hormone, and mortality rates exceeding 20% have been reported even with optimum therapy. ^{[2, 3]}

Signs and symptoms of hypothyroidism

The signs and symptoms characteristic of hypothyroidism are numerous yet often vague and subtle, especially in the early stages of the disease. Note the following:

• Lethargy
• Generalized weakness
• Brittle or thinning hair
• Menstrual irregularity
• Menorrhagia
• Forgetfulness
• Fullness in throat
• Deep, husky voice secondary to mucopolysaccharide infiltration of the vocal cords
• Cold intolerance
• Weight gain/difficulty losing weight
• Muscle/joint pain or weakness
• Inability to concentrate
• Headaches
• Constipation
• Emotional lability
• Depression
• Blurred vision
• Dry hair

Potential physical examination findings include the following:

• Pseudomyotonic reflexes - Prolonged relaxation phase, usually at least twice as long as the contraction phase
• Hypothermia (especially in myxedema coma)
• Skin changes - Dry, cool, coarse, and thickened with a yellowish appearance
• Subcutaneous tissues - Nonpitting, waxy, dry edema secondary to accumulation of polysaccharides
• Loss of axillary and pubic hair
• Pallor
• Loss of outer one third of eyebrows
• Abdominal distention
• Goiter
• Unsteady gait/ataxia
• Pericardial effusion
• Dull facial expression
• Coarsening or huskiness of voice
• Periorbital edema
• Bradycardia, narrow pulse pressure
• Macroglossia
• Thyroidectomy scar - In patients with altered mental status, suggests myxedema coma as a potential cause

Workup in hypothyroidism

The following measurements and studies are indicated in hypothyroidism ^[4] :

• Electrolytes
• Arterial blood gas (ABG)
• Urinalysis

Secondary studies include thyroid function studies, thyroid-stimulating hormone (TSH) levels, free thyroxine (T4) levels, triiodothyronine (T3) resin uptake, free T4 index

Imaging studies include chest radiography, an acute abdominal series, head computed tomography (CT) scanning, and echocardiography.

Management

Patients with myxedema coma may present in extremis; implement initial resuscitative measures, including intravenous (IV) access, cardiac monitoring, and oxygen therapy, as indicated. Mechanical ventilation is indicated for patients with diminished respiratory drive or obtundation.

Evaluate for life-threatening causes of altered mental status (eg, bedside glucose, pulse oximetry).

If myxedema coma is suspected on clinical impression, start IV thyroid hormone treatment. With a diagnosis of myxedema coma, initiate hormonal therapy.

Myxedema coma may lead to profound hemodynamic instability and airway compromise. Emergency physicians should anticipate a potentially difficult airway in patients with myxedema coma. ^[5]

Treat respiratory failure with appropriate ventilatory support. The condition often requires mechanical ventilation.

Avoid medications such as sedatives, narcotics, and anesthetics. Metabolism of these agents may be slowed significantly, causing prolonged effects.