Hypothyroidism and Myxedema Coma

Myxedema Coma and HypothyroidismWhen managing critically ill adults or even adults with “odd complaints,” we often think of the thyroid gland and its potential disorders. The same ease of contemplation when dealing with a child is not as effortless, but there are occasions when we need to remember the importance of that little gland in the neck. We have previously discussed when that gland goes bad and causes Hyperthyroidism and Thyroid Storm. Now, let’s look at Hypothyroidism and Myxedema Coma:

 

Hypothyroidism: Basics

  • Thyroid hormone modulates function in nearly every organ system. [Wassner, 2017]
  • Congenital hypothyroidism is usually diagnosed via neonatal screening programs.
  • Autoimmune hypothyroidism (Hashimoto’s Thyroiditis) is the most common cause of acquired hypothyroidism in children. [Wassner, 2017]
  • Most common symptoms of hypothyroidism: [Wassner, 2017]

 

Myxedema Coma: Basics

  • Myxedema Coma is Rare in children, but lethal.
    • Mostly case reports in children.
    • Mortality reported for myxedema coma between 30-60%.
  • May go unrecognized in young patients (people < 50 years of age {this means that I am still young}) [Root, 2017]
  • Occurs in patients with SEVERE hypothyroidism. [Zhu, 2017]
    • Primary hypothyroidism accounts for >95% of cases of myxedema coma.
    • ~5% of cases are due to pituitary or hypothalamic causes.
  • Pathophysiology: [Root, 2017]
    • Low intracellular triiodothyronine (T3) 
    • Leads to hypothermia
    • Leads to organ dysfunction
      • Reduced of cardiac activity
      • Reduced of brain function
        • May be due to impaired glucose metabolism
        • May be due to impaired cerebral blood flow

 

Myxedema Coma: Presentation

  • Presents with symptoms similar to other life-threatening conditions [Root, 2017]
  • There are not precisely defined clinical criteria for myxedema coma. [Root, 2017]
  • Typically described as having a combination of:
    • Hypotension
    • Bradycardia
    • Hypoventilation and Respiratory Acidosis
      • Respiratory failure can occur
      • The Central Nervous System may become less responsive to hypoxia.
    • Hypothermia
    • Hypoglycemia
    • Changes in Mental Status (although, not necessarily coma)
    • Severe Hypothyroidism
    • Failure to thrive or poor growth history

 

Myxedema Coma: Common Precipitants

  • Infection
    • Most common trigger
    • Particularly pneumonia and sepsis
  • Trauma
  • Cold Exposure
  • Anesthesia

 

Myxedema Coma: Management

  • Treat the underlying inciting event (ie, infection).
  • Levothyroxine replacement
    • There is no current guideline for dosing.
    • Levothyroxine IV dosage of 6.3-10 micrograms/kg/D without a loading dose has been shown to be effective and safe in pediatric patients with myxedema coma. [Zhu, 2017]

 

Moral of the Morsel

  • The Thyroid Gland is super important! When dealing with a critically ill child, think about its role.
  • Think common, but don’t forget complicated! The child with hypothermia and shock most likely has a super bad infection… but that infection may just be triggering myxedema coma.
  • Altered Mental Status and Hypoxia doesn’t mean pneumonia necessarily. Add thyroid dysfunction to your list of items to consider in the patient with altered mental status.

 

References

Zhu Y1, Qiu W, Deng M, Zhu X. Myxedema coma: A case report of pediatric emergency care. Medicine (Baltimore). 2017 May;96(21):e6952. PMID: 28538388. [PubMed] [Read by QxMD]

Wassner AJ1. Pediatric Hypothyroidism: Diagnosis and Treatment. Paediatr Drugs. 2017 Aug;19(4):291-301. PMID: 28534114. [PubMed] [Read by QxMD]

Root JM1, Vargas M, Garibaldi LR, Saladino RA. Pediatric Patient With Altered Mental Status and Hypoxemia: Case Report. Pediatr Emerg Care. 2017 Jul;33(7):486-488. PMID: 27050737. [PubMed] [Read by QxMD]

Thompson MD1, Henry RK. Myxedema Coma Secondary to Central Hypothyroidism: A Rare but Real Cause of Altered Mental Status in Pediatrics. Horm Res Paediatr. 2017;87(5):350-353. PMID: 27631398. [PubMed] [Read by QxMD]

Mathew V1, Misgar RA, Ghosh S, Mukhopadhyay P, Roychowdhury P, Pandit K, Mukhopadhyay S, Chowdhury S. Myxedema coma: a new look into an old crisis. J Thyroid Res. 2011;2011:493462. PMID: 21941682. [PubMed] [Read by QxMD]

Sbrocchi AM1, Chédeville G, Scuccimarri R, Duffy CM, Krishnamoorthy P. Pediatric hypothyroidism presenting with a polymyositis-like syndrome and increased creatinine: report of three cases. J Pediatr Endocrinol Metab. 2008 Jan;21(1):89-92. PMID: 18404977. [PubMed] [Read by QxMD]

Pinsker JE1, Ferry RJ Jr. Pericardial Effusion in the Emergency Department. Endocrinologist. 2004 Jul;14(4):212-215. PMID: 22888197. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Health_Kenya says:

    The ideal way to manage this condition is to prevent it from occurring in the first place. An individual with hypothyroidism should visit their doctor regularly for follow-up and blood testing to be certain that their replacement dose is appropriate.

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