Clinicians need to have a high index of clinical suspicion to make an early diagnosis when myxoedema coma is present. Key to diagnosis is understanding that myxedema coma is diagnosed clinically based on presentation and is supported by other laboratory values. 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. Because most atrisk patients, including those with known hypothyroidism, thyroidectomy or previous radioactive iodine therapy, are routinely followed by readily available tsh.
Myxedema coma is a rare, hardtodiagnose condition with a very high mortality rate. Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in. Myxedema crisis can be treated and managed if it is diagnosed early. Myxedema coma is a rare and potentially fatal manifestation of severe hypothyroidism that can be successfully treated using intravenous levothyroxine. Myxedema coma, also known simply as myxedema, is a rare but potentially deadly manifestation of severe hypothyroidism. Generally, myxedema coma requires several years of untreated hypothyroidism to develop, and usually, it occurs in elderly people who have been without medical care. Diagnosis and treatment myxedema coma, the extreme manifestation of hypothyroidism, is an uncommon but potentially lethal condition.
Some symptoms of myxedema coma include fatigue, lethargy, depression, dry skin, and weight gain. Treatment of myxedema coma with intravenous thyroxine. Myxedema coma is the most severe form of hypothyroidism and carries a high mortality risk. An atypical case of myxedema coma with concomitant.
Because most atrisk patients, including those with known hypothyroidism, thyroidectomy or previous radioactive iodine therapy, are routinely followed by readily available tsh assay. Development of an objective tool for the diagnosis of. These guidelines cover diagnostic and therapeutic aspects of thyroid nodular disease but not thyroid cancer management. 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. 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. The paucity of cases may be due to either underreporting or improvement in the diagnosis and treatment of uncomplicated hypothyroidism. Myxedema coma definition, symptoms, causes, treatment. Pdf myxedema coma clinical presentation, diagnosis and management find, read and cite all the research you. T3 may be a better agent than t4 in the critically ill hypothyroid patient. Prompt recognition and treatment are mandatory for a successful.
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. In the last 7 years numerous reports 115 have appeared in the british medical literature dealing with myxedema, shock, and coma. Myxedema coma is a rare lifethreatening clinical condition in. Thyroid hormone levels are similar to those found in uncomplicated hypothyroidism. To develop diagnostic criteria for myxedema coma mc, a decompensated state of extreme hypothyroidism with a high mortality rate if untreated, in order to facilitate its early recognition and treatment. Diagnostic scoring system for myxedema coma thermoregulatory dysfunction temperature of c points 9535 0 89. Hypothyroidism, also called underactive thyroid or low thyroid, is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. Symptoms can manifest in all organ systems and range in severity based on the degree of hormone deficiency. Patients with hypothyroidism may exhibit a number of physiologic alterations to compensate for the lack of thyroid hormone. Feb 03, 2020 myxedema coma is a severe form of hypothyroidism low thyroid function. The mortality rates may be as high as 25 to 60 percent even with treatment. Progression from hypothyroidism to myxedema and finally to coma, while generally insidious, may be hastened by complicating illness or clouded by overlying myxedema psychosis.
Most patients, however, are not comatose, and the entity rather represents a form of very severe, decompensated hypothyroidism. Predictors of outcome in myxoedema coma critical care full text. Evaluation of transport across the bloodbrain barrier in a primate model. It is essential to identify and treat the condition precipitating the coma. Signs and symptoms are many and are often insidious. A history obtained from family members often reveals antecedent symptoms of thyroid dysfunction followed by progressive lethargy, stupor, and coma. Myxedema coma can be triggered by not taking medicine to treat hypothyroidism. Myxedema coma, first reported in 1880 but not with frequency until 1953, remains poorly understood today. Clinical practice guidelines for hypothyroidism in adults. The construct of myxedema coma sets clinicians up for diagnostic failure. Outcome scale and the extended glasgow outcome scale. The presence of low thyroid hormones such as t3, t4 as well as tsh levels with the presence of the above symptoms are indicative of the condition. Characteristic symptoms are weakness, cold intolerance, mental and physical slowness, dry skin, typical facies, and hoarse voice. A case of myxedema coma presenting as a brain stem infarct in a 74yearold korean woman.
The frequencies of characteristics associated with mc were assessed retrospectively in patients from our institutions in order to derive a semiquantitative diagnostic point. Severe cases, requiring hospitalization can exhibit signs of hypothermia, hypoglycemia, hypotension, respiratory depression, and coma. Clinical characteristics and outcomes of myxedema coma. It still retains a high mortality rate of almost 40% despite aggressive treatment. Findings neck thyroidectomy scar goiter uncommon dermatologic dry, scaly, yellow skin loss of lateral 3rd of eyebrows nonpitting waxy edema of face extremities 41. Before treatment for myxedema coma is initiated, other medical conditions causing similar signs and symptoms should be ruled out. 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 can occur in the lower leg pretibial myxedema and behind the eyes exophthalmos.
Elderly people are at a higher risk of having a poor outcome. Myxedema coma is primarily a clinical diagnosis with features of uncomplicated hypothyroidism but more exaggerated. Patients are typically elderly women who present in winter with deteriorating mental status, hypothermia, bradycardia, and multisystem organ failure. As expected, the clinical manifestations are not restricted to one organ system. Burman, in clinical management of thyroid disease, 2009. Without a rapid diagnosis, myxedema crisis is often fatal. Using the key words myxedema with the word aged, medline files. Prompt recognition and treatment are mandatory for a successful outcome. Hypothyroidism and myxedema coma differential diagnoses. Myxedema, physiological reaction to lack of sufficient thyroid hormone hypothyroidism in the adult. Myxedema crisis coma is a rare lifethreatening clinical condition that represents severe hypothyroidism with physiological decompensation.
Chernow b, burman kd, johnson dl, mcguire ra, obrian jt, wartofsky l, georges lp. However, once the disease has progressed to myxedema coma, the mortality rate may exceed 20% in the treated population. Decompensated hypothyroidism may be conceptualized as hypothyroidism causing organ failure. 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. Results of the total serum thyroxine and free thyroxine index tests usually will confirm the diagnosis. Internationally respected endocrine practice is the journal for clinical endocrinologists. Myxedema coma is a state of decompensated hypothyroidism. Lthyroxine is the treatment of choice for myxedema, but it must be given to elderly patients with extreme caution. Early diagnosis, rapid administration of thyroid hormones and.
A diagnostic scoring system for myxedema coma johns hopkins. May 31, 2017 myxedema coma is the most severe manifestation of hypothyroidism. Signs and symptoms include hypothermia, bradycardia, altered mental status, hypotension, and eventual respiratory. 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. Myxoedema coma occurs almost exclusively in patients over 60 years of age. It can cause a number of symptoms, such as poor ability to tolerate cold, a feeling of tiredness, constipation, depression, and weight gain. However, myxedema from amiodarone therapy is quite rare. The interested reader is directed to the other sources for this information 4. Myxedema coma can be prevented with early treatment of hypothyroidism, taking thyroid medication regularly, and recognition of the warning symptoms of myxedema coma.
Part iv in a series covering the american thyroid association guideline on the treatment of hypothyroidism. Myxedema information including symptoms, diagnosis, misdiagnosis, treatment, causes, patient stories, videos, forums, prevention, and prognosis. 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. Myxedema coma treatment, symptoms, causes, diagnosis. The mortality rates may be as high as 2560% even with best possible treatment 15. Myxedema symptoms, diagnosis, treatments and causes. The term myxedema coma is a misnomer, and myxedema crisis may be an appropriate term as quite a few patients are obtunded, rather than frankly comatose. 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.
Myxedema and coma severe hypothyroidism endotext ncbi. Pdf raionale myxedema coma mc is extremely rare but lethal in pediatric patients with. Myxedema coma in the elderly american board of family. We identified 149 patients diagnosed with myxedema coma out of approximately 19 million inpatients in the database. 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. Myxedema coma is a severe and lifethreatening form of decompensated hypothyroidism with an underlying precipitating factor.
Hypothyroidism is a clinical syndrome in which the deficiency or absence of thyroid hormone slows bodily metabolic processes. However, despite the ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a challenge. Myxedema coma is a rare lifethreatening clinical condition in patients with longstanding severe untreated hypothyroidism, in whom adaptive mechanisms fail to maintain homeostasis. Early diagnosis and treatment is the solution to avoiding the only potentially life threatening complication of untreated hypothyroidism that is myxedema coma. During this period 51 cases were reported in englishlanguage journals. Signs and symptoms include hypothermia, bradycardia, altered mental status.
Myxedema coma is a severe form of hypothyroidism low thyroid function. 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. Myxedema coma in the elderly, although uncommon, is frequently overlooked and has a high mortality rate. It should be informative and educational to deconstruct neurologic representation in film. Diagnosing and treating myxedema and myxedema coma. The diagnosis of myxedema coma was made based on the patients clinical presentation and a score of 65 on the diagnostic scoring system published in 2014 by popoveniuc et al.
Pdf myxedema coma clinical presentation, diagnosis and management find, read and cite all the research you need on researchgate. Mar 24, 2020 the prognosis of hypothyroidism is good with early treatment. 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. In some cases, myxedema condition is also being referred to as underactive thyroid. Jul 06, 2017 without a rapid diagnosis, myxedema crisis is often fatal. Thyroid hormones help control body temperature, heart rate, growth, and weight. 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.
Myxedema coma, the extreme manifestation of hypothyroidism, is an uncommon but potentially lethal condition. Myxedema coma occurs when thyroid hormone levels are not treated or controlled. Although coma as a terminal manifestation of myxedema was first described in 1879, it received little further emphasis until the last decade. The term myxedema coma is a misnomer, and myxedema crisis may be an apt term as quite a few patients are obtunded, rather than frankly comatose. Amiodaroneinduced myxedema coma pubmed central pmc. Thyroid storm and myxedema coma in the emergency department. Find out here why myxedema occurs, and the symptoms. 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.
Occasionally there may be swelling of the front part of the neck due to goiter. The diagnosis of myxedema coma is made by testing for thyroid hormones and observing the symptoms. Diagnosis diagnosis is clinical thyroid panel reflects chronic state 43. Myxedema or severe hypothyroidism is clinical condition where the thyroid gland does not produce any thyroid hormone. Identifying and treating thyroid storm and myxedema coma in the emergency department. It is typically caused by a precipitating event in an untreated or partially treated patient. Untreated or unrecognized hypothyroidism may progress to severe decompensated. Myxedema coma mc is defined as an extreme, uncommon and lifethreatening manifestation of hypothyroidism characterized by a marked and general decompensation. Read more about symptoms, diagnosis, treatment, complications, causes and prognosis. This section covers recommendations for hospitalized patients with hypothyroidism and use of thyroid hormone analogs. The high mortality rate of 2550 % makes early diagnosis and treatment imperative 1, 2. Myxedema coma is a syndrome caused by severe deficiency of thyroid hormone. Symptoms of myxedema coma include fever, changes in mental status or behavior, and body swelling. Myxedema coma discharge care what you need to know.
The typical characteristics of myxedema coma, including bradycardia, hypotension, and hypothermia, were absent in this case. Once the signs and symptoms of myxedema coma are recognized, immediate administration of thyroid replacement is the mainstay of treatment. In myxedema coma the breathing slows, the person has seizures and blood supply to the brain is decreased. Decompensated hypothyroidism myxedema coma emcrit project. Prompt diagnosis and treatment led to quick recovery of the patient. A survey of these reports indicates that 19 out of 25 patients died in spite of vigorous treatment with corticosteroids, vasopressors, thyroid compounds, antibiotics, warming, and electrolyte and fluid correction. Myxedema coma, a rare entity, with a reported 25%65% mortality had no objective criteria for making the diagnosis when we began our study. Myxedema coma is an endocrinologic emergency and is the most clinically severe form of hypothyroidism. C, d nonpitting edema and desquamation of the hands and feet. Myxedema typically present with a distinct facial appearance, hoarse slow speech, and dryness of the skin.
The term myxedema coma is generally seen as misleading since most patients do not initially present in a coma. 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. Myxedema coma or myxedema crisis is a lifethreatening complication of hypothyroidism. Treatment begins with intravenous levothyroxine and intravenous hydrocortisone until associated adrenal.
Wijdicks author film directors recognize that neurologic disease impacts mind and motility and often use it in a plot or defining scene. It can be brought about by removal of the thyroid for any cause, by a cessation of function of the gland, or simply by glandular atrophy. Recommendation 21 of the ata guidelines for the treatment of hypothyroidism jonklaas et al. In spite of ready availability of sensitive thyrotropin assays, the recognition and treatment of myxedema coma remains a clinical challenge. Myxedema is known to occur in various forms of hypothyroidism, and also in graves disease. Amiodarone, an iodinated derivative of benzofuran which bears structural similarity to the thyroid hormones triiodothyronine t3 and tetraiodothyronine thyroxine or t4, can cause thyroid hypo or hyperfunction.
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