Fortunately, it is now a rare presentation of hypothyroidism, likely due to earlier diagnosis as a result of the widespread. The prognosis of hypothyroidism is good with early treatment. Myxedema coma is a clinical diagnosis, so the clinician requires a high index of suspicion. Myxedema coma definition, symptoms, causes, treatment. If severe hypothyroidism occurs in an infant, it is called cretinism. Mar 24, 2020 the prognosis of hypothyroidism is good with early treatment. The diagnosis of myxedema coma is a clinical diagnosis based upon history and physical.
The treatment of subclinical and central hypothyroidism, as well as hypothyroidism in children congenital or acquired, is discussed. Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. Hypothyroidism is a frequently diagnosed and simply treated disease. Patients with hypothyroidism may exhibit a number of physiologic alterations to compensate for the lack of thyroid hormone. Depressive symptoms associated with menopause idsa issues guidelines for. Diagnosis and treatment of thyroid disease during pregnancy. A history obtained from family members often reveals antecedent symptoms of thyroid dysfunction followed by progressive lethargy, stupor, and coma. It is possible that dogs may develop acute hypothyroid crises that respond to iv levothyroxine but do not have myxedema or coma.
If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. This section covers recommendations for hospitalized patients with hypothyroidism and use of thyroid hormone analogs. Signs and symptoms include hypothermia, bradycardia, altered mental status. Carlo oller, emergency physician, talks about severe hypothyroidism, or myxedema coma. Myxedema coma is a rare lifethreatening clinical condition in patients with longstanding severe untreated hypothyroidism, in whom adaptive mechanisms fail to maintain homeostasis. Most patients, however, are not comatose, and the entity rather represents a form of very severe, decompensated hypothyroidism. Myxedema coma as a t rue medical emergency requires a multifaceted approach to treatment in a critical care setting treatment should be instituted in patients with presumed myxedema coma. Sep 15, 2011 myxedema coma is a severe and lifethreatening form of decompensated hypothyroidism with an underlying precipitating factor. The prognosis of myxedema coma usually refers to the likely outcome of myxedema coma. Treatment begins with intravenous levothyroxine and intravenous hydrocortisone until associated adrenal. The prognosis of myxedema coma may include the duration of myxedema coma, chances of complications of myxedema coma, probable outcomes, prospects for recovery, recovery period for myxedema coma, survival rates, death rates, and other outcome possibilities in. Rather, the distinction is based on clinical findings. Myxedema coma treatment, symptoms, causes, diagnosis. Appropriate treatment reverses all the clinical manifestations of hypothyroidism.
If it developed in an adult, it is called myxedema. The exact incidence is controversial, although the condition is becoming increasingly rare due to early detection of hypothyroidism. Mar 24, 2020 hypothyroidism is a clinical syndrome in which the deficiency or absence of thyroid hormone slows bodily metabolic processes. Guidelines american association of clinical endocrinologists. Myxedema coma is usually the result of untreated severe hypothyroidism in combination with a triggering event, such as an infection. It is typically caused by a precipitating event in an untreated or partially treated patient. Instead, the diagnostic coding for these patients included.
Myxedema crisis can be treated and managed if it is diagnosed early. Myxedema coma is a rare, lifethreatening manifestation of severe decompensated hypothyroidism. A person may have lab values identical to a normal hypothyroid state, but a stressful event such as an infection, myocardial infarction or stroke precipitates the myxedema coma state, usually in the elderly. Myxedema coma article about myxedema coma by the free. Consideration of the possible diagnosis of myxedema coma resulted in prompt therapy and symptom resolution within 48 hours. Symptoms can manifest in all organ systems and range in severity based on the degree of hormone deficiency. Jul 06, 2017 without a rapid diagnosis, myxedema crisis is often fatal. In patients with genetic syndromes of resistance to thyroid hormone, the goals of therapy are to improve the symptoms caused by excessive tralpha signaling, while minimizing the symptoms caused by deficient trbeta signaling. This document was prepared as a collaborative effort between the american association of clinical endocrinologists aace, american college of endocrinology ace and associazione medici endocrinologi ame. Myxoedema coma occurs almost exclusively in patients over 60 years of age. In spite of ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a clinical challenge. The high mortality rate of 2550 % makes early diagnosis and treatment imperative 1, 2. Treatment of myxedema coma requires potentially toxic doses of thyroid hormone, and mortality rates exceeding 20% have been reported even with optimum therapy.
Part iv in a series covering the american thyroid association guideline on the treatment of hypothyroidism. Prompt diagnosis and treatment led to quick recovery of the patient. Myxedema and coma severe hypothyroidism endotext ncbi. Myxedema refers to both a form of severe hypothyroidism and a number of effects that hypothyroidism can have on the skin and other body tissues. As of the 1960s, levothyroxine sodium surplanted gradually desiccated thyroid as the preferred treatment modality for hypothyroidism. It is a medical emergency with a high mortality rate. The diagnosis of myxedema coma is initially based upon the history, physical examination, and exclusion of other causes of coma. Symptoms of myxedema coma include fever, changes in mental status or behavior, and body swelling. Some symptoms of myxedema coma include fatigue, lethargy, depression, dry skin, and weight gain. Without a rapid diagnosis, myxedema crisis is often fatal.
Myxedema coma, also known simply as myxedema, is a rare but potentially deadly manifestation of severe hypothyroidism. Elderly patients may present with particularly subtle findings. Myxedema coma is a lifethreatening complication of hypothyroidism, usually occurring in patients with a long history of hypothyroidism. Myxedema coma was diagnosed, and lthyroxine sodium 500. Apr 23, 2019 oslerphile, emergency physician and intensivist suffering from a bad case of knowledge dipsosis.
Free t4 should normalize within four days of starting therapy elshimy et al. May 05, 2019 hypothyroidism is a condition classified by an underactive thyroid gland when the thyroid does not produce enough hormones. Myxedema coma can be prevented with early treatment of hypothyroidism, taking thyroid medication regularly, and recognition of the warning symptoms of myxedema coma. Myxedema coma is defined as severe hypothyroidism resulting in a decompensated metabolic state and mental status change. Decompensated hypothyroidism may be conceptualized as hypothyroidism causing organ failure.
Diagnosis of myxedema coma complicated by renal failure. The mortality rates may be as high as 25 to 60 percent even with treatment. Myxedema information including symptoms, diagnosis, misdiagnosis, treatment, causes, patient stories, videos, forums, prevention, and prognosis. Myxedema coma is a rare fatal condition as a result of longstanding hypothyroidism with loss of the adaptive mechanism to maintain homeostasis. Apr 25, 2018 myxedema coma is a rare lifethreatening clinical condition in patients with longstanding severe untreated hypothyroidism, in whom adaptive mechanisms fail to maintain homeostasis. Childhood cases of myxedema coma are extremely rare. A diagnostic scoring system for the diagnosis of myxedema coma has been proposed.
Myxedema coma, the extreme manifestation of hypothyroidism, is an uncommon but potentially lethal condition. Use of the thyroid hormone analog triiodothyroacetic acid is not. Myxedema symptoms, diagnosis, treatments and causes. Pdf raionale myxedema coma mc is extremely rare but lethal in pediatric patients with hypothyroidism. Myxedema coma is a medical emergency and treatment with thyroid hormone replacement should be started as soon as the diagnosis is suspected and prior to the report of results from the blood samples for studies are obtained. Primary treatment is prompted by the administration of adequate doses of either the thyroid hormone lthyroxine given intravenously or by giving liothyronine via a nasogastric tube. Once the diagnosis of myxedema coma and hypothyroidism is confirmed, thyroid hormone treatment should be started. Burman, in clinical management of thyroid disease, 2009. Although thyroid hormone treatment is highly effective when combined. Signs and symptoms include hypothermia, bradycardia, altered mental status, hypotension, and eventual respiratory. Its characteristics include coma with extreme hypothermia temperature 24 to 32. The paucity of cases may be due to either underreporting or improvement in the diagnosis and treatment of uncomplicated hypothyroidism. Once the signs and symptoms of myxedema coma are recognized. You can help minimize your risk of serious complications by following the treatment plan you and your health care professional design specifically for you.
Mild myxedema coma usually is treated by a general practitioner or internist while moderate to severe myxedema coma is treated and managed by an endocrinologist. Clinical practice guidelines for hypothyroidism in adults. Early diagnosis, rapid administration of thyroid hormones and. Recommendation 21 of the ata guidelines for the treatment of hypothyroidism jonklaas et al.
Elderly people are at a higher risk of having a poor outcome. Clinical endocrinologists worldwide rely on endocrine practice, the official journal of the american association of clinical endocrinologists aace, to keep them on the leading edge of treatment of patients with endocrine diseases. Hypercapnic respiratory failure is another emergency complica. Treatment of myxedema coma usually involves emergency measures to reverse the condition and prevent death. Myxedema coma or myxedema crisis is a lifethreatening complication of hypothyroidism. Thyroid hormone levels are similar to those found in uncomplicated hypothyroidism. Myxedema crisis coma symptoms, causes, and treatment. The diagnosis is suspected clinically and confirmed with tft elevated tsh levels and low levels of free t4 and t3 the degree of tft abnormalities does not distinguish hypothyroidism from myxedema coma. We report a case of a 5yearold girl transferred to a tertiary care pediatric emergency department with hypoxemia and altered mental status. Myxedema coma is a rare but severe complication of myxedema.
Note that the term coma is a misnomer, as most patients present with an altered mental state rather than frank coma. Dec 01, 2000 while myxedema coma carries a significant mortality rate even with appropriate testing and treatment, an early diagnosis of hypothyroidism may well save a patients life. Physicians should not be surprised in case of normal or low tsh and low free t4. However, if the condition is suspected, treatment should be started. We developed an objective screening tool for myxedema coma to more easily identify patients and examine the best treatment method in future prospective studies to reduce the mortality of this entity. Because most atrisk patients, including those with known hypothyroidism, thyroidectomy or previous radioactive iodine therapy, are routinely followed by readily available tsh. The diagnosis of myxedema coma is made when the three key diagnostic features of myxedema coma are present, which include altered mental status, hypothermia or absence of fever and a precipitating event such as cold exposure, infection, drugs. All patients with an admitting diagnosis of myxedema coma recorded in their charts between january 1, 2005 and june, 2010 were identified.
The decreased t 4 secretion results in a modest decrease in the serum concentration of free thyroxine. It occurs primarily in women in 30 to 60 years old. Even with early diagnosis and treatment of myxedema. It is a medical emergency and, even with early diagnosis and treatment, the. Even though rare, the diagnosis of myxedema coma should be considered in any.
Treatment should be started when a patient presents with coma and chronic kidney disease with or without dialysis, even in the absence of hypotension, hypothermia, hyponatremia, and hypoxemia. The interested reader is directed to the other sources for this information 4. It is a lifethreatening complication with a mortality rate of 2560 percent and tends to affect older adults. Myxedema coma definition, causes, symptoms, diagnosis and. Therefore, myxedema coma must be considered in the differential diagnosis.
Myxedema coma is rare in dogs but the diagnosis is complicated by the fact that, as in humans, dogs with myxedema coma often do not have myxedema and are rarely comatose. Hypothyroidism and myxedema coma differential diagnoses. Apr 16, 2014 myxoedema coma is around four times more common in women than in men reflecting the higher incidence of hypothyroidism in women, which has a prevalence of 8% in women aged over 50. Myxedema coma accompanied by sick sinus syndrome and. It is essential to identify and treat the condition precipitating the coma. Myxedema coma is an endocrinologic emergency and is the most clinically severe form of hypothyroidism. Even though rare, the diagnosis of myxedema coma should be considered in any hypothermic, obtunded patient.
In the patient with central hypothyroidism, the diagnosis of myxedema coma maybe very difficult, as serum tsh concentrations will be normal or low. Diagnostic scoring system for myxedema coma thermoregulatory dysfunction temperature of c points 9535 0 89. May 31, 2017 myxedema coma is the most severe manifestation of hypothyroidism. Complications of myxedema and hypothyroidism include.
Prior to initiation of t4, intravenous stress dose steroids are typically administered due to the risk of coex. Even with early diagnosis and treatment of myxedema coma, the mortality rate is. Dec 26, 2018 myxedema crisis or coma, is a rare and potentially fatal condition caused by low levels of thyroid hormones produced by the thyroid gland. Decompensated hypothyroidism myxedema coma emcrit project.
Our case highlights the need to consider myxedema coma as a differential diagnosis for altered mental status in the emergency room and use of screening tools for effective selection of patients. If the diagnosis is suspected, immediate management is necessary before. Myxedema coma is a rare lifethreatening clinical condition in. Internationally respected endocrine practice is the journal for clinical endocrinologists. Free t4 is best measured by equilibrium dialysis, though this is performed in. It is classically characterized by thickened, nonpitting edema of the skin diffusely associated with severe chronic hypothyroidism.
Hypothyroidism due to any cause including autoimmune disease, iodine deficiency, congenital abnormalities or medications like lithium and amiodarone can precipitate myxedema coma if left untreated. Thyroid disorders, although rare, should be considered in the postoperative. Myxedema coma is defined as severe hypothyroidism leading to decreased mental. Myxedema coma is a medical emergency that requires immediate attention. Find out here why myxedema occurs, and the symptoms. Since 95% of cases of myxedema coma are due to primary hypothyroidism, the laboratory findings include an elevated serum tsh and low or undetectable total and free serum t4 concentrations. If these homeostatic mechanisms are overwhelmed by factors such as infection. Myxedema coma is primarily a clinical diagnosis with features of uncomplicated hypothyroidism but more exaggerated. Myxoedema coma may present with the classic myxoedema facies characterised by macroglossia, ptosis and periorbital oedema, however, not all patients exhibit the full list of classic findings, and a coma is not required for diagnosis.
The construct of myxedema coma sets clinicians up for diagnostic failure. Correct severe hyponatremia with saline and free water restriction. However, despite the ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a challenge. These guidelines cover diagnostic and therapeutic aspects of thyroid nodular disease but not thyroid cancer management. Myxedema coma is a lifethreatening complication of untreated. According to the most recent ata guidelines, the recommended initial. Diagnostic scoring system for myxedema coma thermoregulatory dysfunction temperature of c.