"Myxedema Coma-Induced Heart Failure with Reduced Ejection Fraction: Un" by Mohammad Ali Mozaffari, Batool Shukr et al.
 

Document Type

Conference Proceeding

Publication Date

5-3-2024

Abstract

Introduction Myxedema coma is a rare condition with a high mortality rate. It poses the risk of cardiovascular complications, typically affects elderly females, and is often triggered by an underlying infection or systemic illness in the setting of preexisting severe hypothyroidism. Patients may exhibit multiorgan dysfunction with altered mentation ranging from disorientation and lethargy to obtundation and coma. Other physical exam findings may include dry scaly skin, non-pitting edema, delayed reflexes, bradycardia, and hypothermia. Prompt diagnosis and early treatment are crucial to reducing mortality rates associated with this severe condition. Case description A 74-year-old female with no known past medical history except for smoking who had not sought any medical attention for the past 30 years was brought to the ED for increased weakness and fatigue over the past month, which worsened three days before presentation. She had altered mentation, hypothermia (84.8F), and sinus bradycardia with 1st-degree AV block. TSH42.44, Free T4< 0.4, TPO Ab81, thyroglobulin Ab< 20, Cortisol14.6, ACTH20, Cr1.7, BUN46, BNP648, and high-sensitivity troponin19. Head CT showed no acute intracranial process. Furthermore, she was found to have severe sepsis secondary to bilateral lower extremity cellulitis and was started on broad-spectrum antibiotics. With evidence of myxedema coma, the patient was intubated, transferred to CCU, rewarmed, and treated with IV hydrocortisone and IV levothyroxine. TTE revealed a normal-sized LV with LVEF 15% and severe global hypokinesis. Due to AKI, she was not a good candidate for a left heart catheterization. She underwent a myocardial SPECT stress test, which was negative for stress-induced ischemia, suggestive of non-ischemic cardiomyopathy. The patient was initiated on maximally tolerated guideline-directed medical therapy for heart failure. Follow-up labs revealed TSH 7.68, T4 0.8, and T3< 1.5, which improved to 2 in the following day. A month later, her functional status was NYHA class III and repeated TTE revealed LVEF to 40%, mild global hypokinesis, and grade II diastolic dysfunction. Clinical significance Myxedema coma is rare, with a yearly incidence of 0.2-1.08/million, yet a life-threatening emergency with a high mortality rate of 30-60%, necessitating a comprehensive understanding of its signs and symptoms for timely diagnosis and appropriate treatment. Pathophysiological mechanisms involve impaired myocardial contractility, reduced cardiac output, and altered vascular resistance. The cardiac myocyte lacks significant deiodinase activity and thus depends on T3 from the bloodstream. Cross-sectional studies suggest that nearly 30% of individuals suffering from congestive heart failure (CHF) exhibit reduced T3 levels, which serves as a robust indicator for both all-cause and cardiovascular mortality. This case underscores the importance of considering myxedema coma in the differential diagnosis of obtundation and symptoms of cardiovascular compromise. Discussion Thyroid disease is common, affecting 9-15% of adult females; however, overt hypothyroidism impacts almost 3% of adult females. The cardiovascular presentation of myxedema coma is often serious and poses a potential threat to life. Nonetheless, the development of overt CHF is a rare phenomenon. In most instances, identifying and addressing the underlying thyroid disorder leads to reversible cardiovascular changes. Thus, early recognition is crucial to facilitate timely intervention and optimize patient outcomes.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2024 Resident and Medical Student Day, May 3, 2024, Troy, MI

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