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Perioperative management of a patient with myxedema coma and septicemic shock.
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MedLine Citation:
PMID:  23559735     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Myxedema coma is a life-threatening but uncommon complication of long-standing, neglected hypothyroidism. It was first reported by Ord in 1879. Till date only around 200 cases have been reported in literature. The incidence in European countries is 0.22 per million per year. No epidemiological data is available from the Indian subcontinent. We are reporting the case of an elderly lady who went into life-threatening myxedema coma along with septicemic shock, and was successfully treated with oral thyroxine.
Authors:
Neha Baduni; Sunil Kumar Sinha; Manoj K Sanwal
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine     Volume:  16     ISSN:  0972-5229     ISO Abbreviation:  Indian J Crit Care Med     Publication Date:  2012 Oct 
Date Detail:
Created Date:  2013-04-05     Completed Date:  2013-04-08     Revised Date:  2013-04-08    
Medline Journal Info:
Nlm Unique ID:  101208863     Medline TA:  Indian J Crit Care Med     Country:  India    
Other Details:
Languages:  eng     Pagination:  228-30     Citation Subset:  -    
Affiliation:
Department of Anaesthesiology and Intensive Care, Lady Hardinge Medical College and Association Hospitals, New Delhi, India.
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Journal Information
Journal ID (nlm-ta): Indian J Crit Care Med
Journal ID (iso-abbrev): Indian J Crit Care Med
Journal ID (publisher-id): IJCCM
ISSN: 0972-5229
ISSN: 1998-359X
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © Indian Journal of Critical Care Medicine
open-access:
Print publication date: Season: Oct-Dec Year: 2012
Volume: 16 Issue: 4
First Page: 228 Last Page: 230
PubMed Id: 23559735
ID: 3610460
Publisher Id: IJCCM-16-228
DOI: 10.4103/0972-5229.106510

Perioperative management of a patient with myxedema coma and septicemic shock
Neha Baduniaff1
Sunil Kumar Sinhaaff1
Manoj K. Sanwal1
From: Department of Anaesthesiology and Intensive Care, Lady Hardinge Medical College and Association Hospitals, New Delhi, India
1Department of Anaesthesiology and Intensive Care, GB Pant Hospital, New Delhi, India
Correspondence: Correspondence: Dr. Neha Baduni, GH 12 / 183, Paschim Vihar, New Delhi, India. E-mail: baduni.neha@gmail.com

Introduction

Myxedema coma is a rare life-threatening complication of long-standing, neglected hypothyroidism. Till date only around 200 cases have been reported. We are reporting the case of an elderly lady with life-threatening myxedema coma and septicemic shock who was successfully treated with oral thyroxine.


Case Report

A 61-year-old lady, known case of hypothyroidism for 20 years, was admitted in surgical emergency with complaints of abdominal pain and distension for 3 days. She had no recent thyroid function test (TFT) reports.

On examination, she was found to be drowsy but arousable. Her pulse rate (PR) was 68/min., blood pressure (BP) 140/86 mmHg, temperature 36.5°C, respiratory rate (RR) 10/min. Her investigations were Hb -8.8 gm%, total leucocyte count-12,400/mm3, serum Na+-112 meq/l (normal range 135-145 meq/l), serum K+-2.2 meq/l (normal range 3.5-5.5 meq/l). Her liver function tests, kidney function tests and chest X-ray were normal and ECG showed low voltage complexes. A sample for TFT was immediately sent. Abdominal ultrasound revealed a mass in right iliac fossa suggesting appendicular lump along with paralytic ileus. She was started on conservative management along with correction of electrolytes and active rewarming. Meanwhile her TFT showed severe hypothyroidism with T3 being 62 ng/dL (normal range 100-180 ng/ dL), T4-2.2 μg/dL (normal range 4-12 μg/dL) and TSH-18 μU/ ml (normal range 0.5-6 μU/ml). Her dose of eltroxin was elevated to 100 μg/day.

Her abdominal distension increased over the next 48 hours and a contrast-enhanced CT scan of abdomen revealed intestinal perforation. She was immediately taken up for laparotomy. Preoperatively, the patient was still drowsy but stable hemodynamically.

General anesthesia was induced using rapid sequence induction. Immediately after induction, she had systolic hypotension (85 mmHg), managed with fast crystalloids. There was a further drop in her blood pressure after the abdomen was opened during surgery, necessitating dopamine infusion along with noradrenaline infusion. Her entire colon was found to be gangrenous and extended right hemicolectomy was done. Intravenous steroids were given. Surgery lasted for 2 hours and she was shifted to ICU for elective ventilation

When received in ICU, patient was hypothermic (temperature 34.6°C) and hypotensive (systolic BP-68 mmHg). Rewarming was started with of warm fluids, bladder lavage with warm saline and electric blanket. Three litres of lactated ringer's solution was pushed intravenously. Adrenaline infusion was now added. This managed to maintain her systolic BP to around 85 mmHg. Unfortunately parental thyroxine was not available so we decided to give eltroxine tablet (500 μg) once daily via Ryle's tube. This along with aggressive antibiotic coverage, steroid supplementation and inotropic support gradually improved her blood pressure over the next 24 hours. Her TFT also showed marked improvement after 3 days. Her eltroxine was titrated to 150 μg twice a day now.

Over the next 2 days, her inotropic support was gradually tapered off and stopped. Her eltroxin dose was also decreased to 100 μg twice a day. Finally on postoperative day 5, she was extubated and shifted to the postoperative ward.


Discussion

Myxedema coma is an extreme complication of hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration. It occurs almost exclusively in age group 60 years and above, with 80% preponderance in females, as seen in our patient.[1, 2]

More than 80% of cases of myxedema coma occur in winters, probably due to age-related loss of ability to sense temperature and lower production secondary to hypothyroidism.[1] Other events which can precipitate it include infections, cardiovascular accidents, congestive cardiac failure and certain drugs.[3, 4] We presume that in our patient the precipitating factors included winter season, septicemia and stress of surgery and anesthesia.

Myxedema coma causes drastic decrease in metabolic rate, hypoventilation, hypotension, hypothermia, decreased mental state progressing to coma and decreased cardiac output.[5]

A common misconception is that a patient must be comatosed to be diagnosed with myxedema coma. However, most patients exhibit neither edema nor coma. Instead the cardinal manifestation is a deterioration of the patient's mental status.[6, 7]

It is said that long-standing hypothyroid patients have associated hypopituitarism.[3] There have been reports of myxedema coma with coexisting adrenal crisis.[8, 9] Preoperative cortisol level determination along with perioperative steroid supplementation is advised. Although we could not get cortisol level determined, empirical steroid supplementation aided in the recovery of our patient.

Mortality in untreated or unrecognized myxedema coma reaches nearly 100%. Even with optimum therapy, mortality rate as high as 30-60% has been reported.[10, 11] Dutta et al. did a study to determine the various predictors of outcome in myxedema coma and concluded that various factors associated with increased mortality included bradycardia, need for mechanical ventilation, hypothermia, sepsis, hypotension and intake of sedative drugs.[12] In our patient most of these factors were present but were managed aggressively and judiciously. In literature, intravenous thyroid hormone supplementation has been advised for the treatment of myxedema coma but since it was not available, early supplementation of a higher dose (500 μg/day) of oral thyroxine was started via the Ryle's tube. Suspicion and empirical treatment of adrenocortical suppression prevented further deterioration of our patient. The good outcome of our patient despite severe hypothyroidism and septicemic shock with gangrene occurred most probably due to the fact that she was already receiving eltroxine, though suboptimal dose and our aggressive inotrope therapy, fluid management and multiple antibiotics.

To conclude, the combination of myxedema coma and sepsis in a patient can be lethal. Early institution of thyroxine supplementation, even via oral route, along with inotropic support and steroid supplementation, can improve the prognosis.


Notes

Source of Support: Nil

Conflict of Interest: None declared.

References
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2. David PJ,Davis FB. Hypothyroidism in the elderlyCompr TherYear: 19841017236426851
3. Wall CR. Myxoedema coma: Diagnosis and treatmentAm Fam PhysicianYear: 20006224859011130234
4. Santiago R,Rashkin MC. Lithium toxicity and myxoedema coma in an elderly womanJ Emerg MedYear: 199086362191030
5. Wartofsky L. Myxedema comaEndocrinol Metab Clin North AmYear: 20063568798 vii-viii. 17127141
6. Jordan RM. Myxedema coma: Pathophysiology, therapy, and factors affecting prognosisMed Clin North AmYear: 199579185947808091
7. Nicoloff JT,LoPresti JS. Myxedema coma. A form of decompensated hypothyroidismEndocrinol Metab Clin North AmYear: 199322279908325287
8. Kasperlik-Zaluska AA,Czarnocka B,Czech W,Walecki J,Makowska AM,Brzeziñski J,et al. Secondary adrenal insufficiency associated with autoimmune disorders: A report of twenty-five casesClin Endocrinol (Oxf)Year: 1998497798310209566
9. Roosens B,Maes E,Van Steirteghem A,Vanhaelst L. Primary hypothyroidism associated with secondary adrenocortical insufficiencyJ Endocrinol InvestYear: 1982525146294170
10. Werner SC,Ingbar SH,Braverman LE,Utiger RD. Werner and IngbarsThe thyroid: A fundamental and clinical textYear: 20008th edPhiladelphiaLipincott Williams and Wilkins
11. Arlot S,Debussche X,Lalau JD,Mesmacque A,Tolani M,Quichard J,et al. Myxodema coma: Response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatmentIntensive Care MedYear: 1991171682037720
12. Dutta P,Bhansali A,Masoodi SR,Bhadada S,Sharma N,Rajput R. Predictors of outcome in myxedema coma: A study from a tertiary care centreCrit CareYear: 200812R118173846

Article Categories:
  • Case Report

Keywords: Inotropes, myxedema coma, parenteral elroxine, septicemia, shock, thyroxine.

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