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Annals of Intensive Care Mar 2023Severe hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes of the most severe forms...
BACKGROUND
Severe hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management, and in-ICU and 6-month survival rates of these patients.
METHODS
We conducted a retrospective, multicenter study over 18 years in 32 French ICUs. The local medical records of patients from each participating ICU were screened using the International Classification of Disease 10th revision. Inclusion criteria were the presence of biological hypothyroidism associated with at least one cardinal sign among alteration of consciousness, hypothermia and circulatory failure, and at least one SH-related organ failure.
RESULTS
Eighty-two patients were included in the study. Thyroiditis and thyroidectomy represented the main SH etiologies (29% and 19%, respectively), while hypothyroidism was unknown in 44 patients (54%) before ICU admission. The most frequent SH triggers were levothyroxine discontinuation (28%), sepsis (15%), and amiodarone-related hypothyroidism (11%). Clinical presentations included hypothermia (66%), hemodynamic failure (57%), and coma (52%). In-ICU and 6-month mortality rates were 26% and 39%, respectively. Multivariable analyses retained age > 70 years [odds ratio OR 6.01 (1.75-24.1)] Sequential Organ-Failure Assessment score cardiovascular component ≥ 2 [OR 11.1 (2.47-84.2)] and ventilation component ≥ 2 [OR 4.52 (1.27-18.6)] as being independently associated with in-ICU mortality.
CONCLUSIONS
SH is a rare life-threatening emergency with various clinical presentations. Hemodynamic and respiratory failures are strongly associated with worse outcomes. The very high mortality prompts early diagnosis and rapid levothyroxine administration with close cardiac and hemodynamic monitoring.
PubMed: 36892784
DOI: 10.1186/s13613-023-01112-1 -
SAGE Open Medical Case Reports 2022Myxedema coma is an emergency that develops from non-diagnosed or severe hypothyroidism and requires early recognition and management. Cardiac manifestations are...
Myxedema coma is an emergency that develops from non-diagnosed or severe hypothyroidism and requires early recognition and management. Cardiac manifestations are uncommon and pose a challenge in the recognition of myxedema coma. We present the case of a 76-year-old male with a history of thyroidectomy secondary to a follicular carcinoma, who presented with dyspnea, generalized edema, drowsiness, disorientation, memory loss, and episodic generalized tonic-clonic seizures. Antiepileptic and diuretic treatment for seizures and heart failure exacerbation did not improve the symptoms. Further blood analysis revealed a thyroid-stimulating hormone and free thyroxine of 163 mUL/L and 0.64 ng/dL, respectively. Treatment with intravenous hydrocortisone and levothyroxine led to progressive clinical improvement. Uncommon clinical manifestations such as cardiac and non-specific neurologic symptoms should be considered as manifestations of myxedema coma. A comatose mental status is not a universal manifestation, and milder symptoms should be considered. An adequate assessment, including diagnostic scores and prompt hormonal supplementation prevents fatal consequences.
PubMed: 36225224
DOI: 10.1177/2050313X221130227 -
Frontiers in Endocrinology 2023Previous observational studies have reported a positive correlation between obesity and susceptibility to hypothyroidism; however, there is limited evidence from...
INTRODUCTION
Previous observational studies have reported a positive correlation between obesity and susceptibility to hypothyroidism; however, there is limited evidence from alternative methodologies to establish a causal link.
METHODS
We investigated the causal relationship between obesity and hypothyroidism using a two-sample bidirectional Mendelian randomization (MR) analysis. Single-nucleotide polymorphisms (SNPs) associated with obesity-related traits were extracted from a published genome-wide association study (GWAS) of European individuals. Summarized diagnostic data of hypothyroidism were obtained from the UK Biobank. Primary analyses were conducted using the inverse variance-weighted (IVW) method with a random-effects model as well as three complementary approaches. Sensitivity analyses were performed to ascertain the correlation between obesity and hypothyroidism.
RESULTS
MR analyses of the IVW method and the analyses of hypothyroidism/myxedema indicated that body mass index (BMI) and waist circumference (WC) were significantly associated with higher odds and risk of hypothyroidism. Reverse MR analysis demonstrated that a genetic predisposition to hypothyroidism was associated with an increased risk of elevated BMI and WC, which was not observed between WC adjusted for BMI (WCadjBMI) and hypothyroidism.
DISCUSSION
Our current study indicates that obesity is a risk factor for hypothyroidism, suggesting that individuals with higher BMI/WC have an increased risk of developing hypothyroidism and indicating the importance of weight loss in reducing the risk of hypothyroidism.
Topics: Humans; Genome-Wide Association Study; Mendelian Randomization Analysis; Hypothyroidism; Causality; Obesity
PubMed: 38260160
DOI: 10.3389/fendo.2023.1287463 -
Endocrinology, Diabetes & Metabolism... Jun 2021Myxedema coma is an important differential diagnosis in critically ill patients. Early diagnosis and treatment are paramount but challenging due to a lack of diagnostic...
SUMMARY
Myxedema coma is an important differential diagnosis in critically ill patients. Early diagnosis and treatment are paramount but challenging due to a lack of diagnostic criteria. We report a case about a patient who suffered from untreated hypothyroidism for several years. Before the correct diagnosis was made, he was admitted three times due to severe constipation. Eventually, he developed myxedema coma in connection with a urinary tract infection. The course was complicated by recurrent seizures, and neuroimaging showed bilateral hygromas. Hormone replacement therapy resulted in complete recovery and regression of hygromas. To the best of our knowledge, this is the first time hygroma is reported in association with myxedema coma.
LEARNING POINTS
Myxedema coma is a difficult diagnosis to make due to a lack of diagnostic criteria. Cardinal features include hypothermia, bradycardia, gastrointestinal symptoms, pericardial/pleural effusions and affection of CNS. Anemia and hyponatremia are common. In case of suspected myxedema coma, neuroimaging should be a part of the evaluation in most cases. There is a possible association between longstanding/severe hypothyroidism and hygroma.
PubMed: 34156348
DOI: 10.1530/EDM-21-0067 -
Reviews in Cardiovascular Medicine Jun 2020Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma;... (Review)
Review
Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma; however, not all bradycardia with hypothyroidism are sinus bradycardia. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.
Topics: Aged, 80 and over; Bradycardia; Cardiac Pacing, Artificial; Coma; Female; Heart Rate; Hormone Replacement Therapy; Humans; Hypothyroidism; Myxedema; Severity of Illness Index; Thyroxine; Treatment Outcome
PubMed: 32706217
DOI: 10.31083/j.rcm.2020.02.26 -
JCEM Case Reports Jan 2023Pretibial myxedema (PTM), also called thyroid dermopathy, is a dreaded and potentially debilitating manifestation of thyroid disease, more commonly Graves' disease,...
Pretibial myxedema (PTM), also called thyroid dermopathy, is a dreaded and potentially debilitating manifestation of thyroid disease, more commonly Graves' disease, which can occur at any time over the course of the disease. No substantial long-term therapies have been able to target the condition, and management has typically been supportive (eg, compression socks, weight loss), with courses of moderate-intensity steroids. Teprotumumab has been approved for the management of thyroid eye disease (TED), and it is believed that the 2 share a similar pathophysiology likely related to type 1 insulin-like growth factor receptor, which may explain why some patients have also experienced improvement in PTM. Here we present a patient who received 8 doses of teprotumumab for TED who, over the course of management and into follow-up, experienced significant improvement in her pretibial myxedema. The patient noted considerable improvement in quality of life and ability to perform daily activities. We present this case to consider further investigation into the utilization of teprotumumab for thyroid disease-related PTM in patients with impaired quality of life.
PubMed: 37908268
DOI: 10.1210/jcemcr/luac037 -
Cureus Jun 2023This systematic review aimed to explore whether elderly patients administered amiodarone were susceptible to developing myxedema coma. Utilizing the Cochrane guidelines,... (Review)
Review
This systematic review aimed to explore whether elderly patients administered amiodarone were susceptible to developing myxedema coma. Utilizing the Cochrane guidelines, a comprehensive review of databases such as Medline (PubMed), Science Direct, CINAHL Cochrane, and Google Scholar was undertaken to examine case reports on amiodarone-induced myxedema coma. Following stringent criteria for inclusion, 12 pertinent case reports were identified. These findings suggested a high probability of myxedema coma development in patients who had been administered amiodarone. Specifically, patients who received an oral dosage of 100-200 mg of amiodarone were reported to have developed bradycardia and hypothermia alongside elevated thyroid-stimulating hormone (TSH) levels. Upon diagnosis, the majority of patients were treated with a regimen of levothyroxine and hydrocortisone medication. Despite the myriad potential causes of myxedema coma complicating the diagnosis, it was found that through a combination of clinical symptoms and serum TSH measurements, a confirmed diagnosis could be reached. Furthermore, it was observed that amiodarone-induced myxedema coma responded favorably to treatment with levothyroxine and glucocorticoids.
PubMed: 37492810
DOI: 10.7759/cureus.40893 -
Acta Bio-medica : Atenei Parmensis Nov 2021Decompensated hypothyroidism, formerly known as myxedema coma, represents the most extreme clinical expression of severe primary or secondary hypothyroidism in which... (Review)
Review
Decompensated hypothyroidism, formerly known as myxedema coma, represents the most extreme clinical expression of severe primary or secondary hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration. The exact incidence of myxedema coma in adults is not known, but some authors have estimated that is approximately 0.22 per 100.0000 per year in the western world. Myxedema coma is more common in females and during winter months. The diagnosis of myxedema coma is primarily clinical with supportive evidence of the abnormal thyroid function tests. Clinical features vary depending on a several factors including the age of onset and the severity of the disease. In the majority of patients (95%), the cause of underlying hypothyroidism is autoimmunity, i.e., Hashimoto thyroiditis or congenital abnormalities. Rarely it occurs in secondary (central) hypothyroidism, due to thyrotropin deficiency related to pituitary disease, or pituitary-thyroid damage due to iron overload. Treatment consists of thyroid hormone replacement, correction of electrolyte disturbances, passive rewarming, treatment of infections, respiratory and hemodynamic support, and administration of stress-dose glucocorticoids. Prognosis seems to be better in children and adolescents compared to adults. The present review reports personal experience and the literature data on 13 patients.
Topics: Adolescent; Adult; Child; Coma; Emergencies; Female; Humans; Hypothyroidism; Myxedema; Thyroid Function Tests
PubMed: 34738556
DOI: 10.23750/abm.v92i5.12252 -
Cureus Jan 2022Severe, uncorrected hypothyroidism can result in a dangerous hypometabolic state leading to myxedema crisis, a rare but life-threatening illness. Myxedema crisis is a...
Severe, uncorrected hypothyroidism can result in a dangerous hypometabolic state leading to myxedema crisis, a rare but life-threatening illness. Myxedema crisis is a clinical diagnosis. The treatment for severe hypothyroidism and myxedema crisis is multifaceted, centered around thyroid hormone replacement, identification and treatment of precipitating factors, and intricate supportive care. Even with early and aggressive treatment, the myxedema crisis carries a high mortality rate. We present a case of iatrogenic hypothyroidism with severe features in a patient concurrently taking methimazole and amiodarone. This case illustrates the need for a high index of suspicion for patients on treatment for hyperthyroidism with any inciting event. The complexity of this case was rooted in polypharmacy, specialized care for numerous comorbidities complicated by significant strain on ED resources and personnel due to a global pandemic, resulting in severe complications. This case brings to light the need for immediate and appropriate treatment and critical care consultation for admission to a unit with an advanced level of care, as is the case for all patients with concern for severe hypothyroidism or myxedema crisis.
PubMed: 35186597
DOI: 10.7759/cureus.21339 -
Endocrinology, Diabetes & Metabolism... Jan 2024Myxoedema coma is a severe form of hypothyroidism with multiple organ dysfunction, characterised by an altered state of consciousness and hypothermia. Intravenous...
SUMMARY
Myxoedema coma is a severe form of hypothyroidism with multiple organ dysfunction, characterised by an altered state of consciousness and hypothermia. Intravenous thyroid hormone replacement therapy is the preferred treatment for myxoedema. The mortality rate associated with this disease is high, and early detection and intervention are essential. Supraglottal myxoedema is a rare form of periglottic oedema and can be fatal. A previously healthy 66-year-old man presented with impaired consciousness, hypothermia, and nonpitting oedema. Blood tests revealed the presence of hypothyroidism and respiratory acidosis. He was intubated for type 2 respiratory failure; however, severe laryngeal oedema made the procedure difficult to perform. Oral thyroid hormone therapy was initiated under the diagnosis of myxoedema coma. Tracheostomy was performed because of prolonged type 2 respiratory failure and laryngeal oedema. Three weeks after admission, the patient was weaned off the ventilator. Approximately a week later, laryngeal oedema improved, and the tracheostomy tube was removed. The patient was discharged and remained stable for 3 months. This case report describes a patient with comatose myxoedema and supraglottic oedema who was successfully treated with oral medication alone. This case shows that supraglottic oedema should be considered even in the absence of wheezing or other signs of upper airway obstruction.
LEARNING POINTS
Myxoedema coma is a differential diagnosis of respiratory acidosis. In myxoedematous coma, the possibility of difficult intubation due to supraglottic oedema should be considered. Tracheostomy should be considered for supraglottic myxoedema, which often results in prolonged ventilator use. Supraglottic myxoedema can be treated with oral medications.
PubMed: 38377682
DOI: 10.1530/EDM-23-0078