Coma mixedematoso asociado a infección por SARS-CoV-2 / Myxedema coma associated with SARS-CoV-2 infection / Coma mixedematoso associado à infecção por SARS-CoV-2

Resumen: Aunque se sabe que la infección por SARS-CoV-2 es una causa importante de enfermedad pulmonar, se han observado múltiples manifestaciones extrapulmonares asociadas a COVID-19. Existen en la literatura reportes de tirotoxicosis secundarios a COVID-19, pero los casos de hipotiroidismo descompensado por COVID-19 son escasos. Reportamos el caso de una paciente de 37 años con obesidad que presentó coma mixedematoso asociado a infección por SARS-CoV-2. El estado proinflamatorio secundario a obesidad, el daño directo a la glándula tiroidea por SARS-CoV-2 y la elevación de mediadores inflamatorios en sangre observados durante la infección viral podrían ser mecanismos que desencadenen el coma mixedematoso. En pacientes con COVID-19 severo es importante la búsqueda intencionada de signos de coma mixedematoso y su confirmación con un perfil tiroideo al ingreso hospitalario.

Abstract: Although SARS-CoV-2 infection is known to be an important cause of lung disease, multiple extrapulmonary manifestations associated with COVID-19 have been observed. There are reports of thyrotoxicosis secondary to COVID-19 in the literature, but cases of decompensated hypothyroidism due to COVID-19 are rare. We report the case of a 37-year-old female patient with obesity who presented myxedema coma associated with SARS-CoV-2 infection. The pro-inflammatory state secondary to obesity, direct damage to the thyroid gland by SARS-CoV-2, and the elevation of inflammatory mediators in the blood observed during viral infection could be mechanisms that trigger myxedema coma. In patients with severe COVID-19, the intentional search for signs of myxedema coma and its confirmation with a thyroid profile at hospital admission is important.

Resumo: Embora a infecção por SARS-CoV-2 seja conhecida por ser uma causa importante de doença pulmonar, foram observadas várias manifestações extrapulmonares associadas ao COVID-19. Há relatos na literatura de tireotoxicose secundária à COVID-19, mas os casos de hipotireoidismo descompensado por COVID-19 são raros. Relatamos o caso de um paciente de 37 anos com obesidade que apresentou coma mixedematoso associado à infecção por SARS-CoV-2. O estado pró-inflamatório secundário à obesidade, o dano direto à glândula tireoide pelo SARS-CoV-2 e a elevação de mediadores inflamatórios no sangue observados durante a infecção viral podem ser mecanismos que desencadeiam o coma mixedematoso. Em pacientes com COVID-19 grave, é importante a busca intencional de sinais de coma mixedematoso e sua confirmação com perfil tireoidiano na admissão hospitalar.

A study of serum thyroid stimulating hormone levels, and its correlation with clinical features and delayed diagnosis of hypothyroidism in central India

Background: The clinical manifestations of hypothyroidism are variable, depending upon its cause, duration and severity. The spectrum extends from subclinical to overt hypothyroidism to myxedema coma. A high degree of suspicion is thus required in order to appreciate the clinical manifestation of the disorder to reach a diagnosis. Purpose of this study was to correlate serum TSH level with severity of clinical manifestations and evaluate possible cause of delay in the diagnosis.Methods: A cross section observational and descriptive study for the assessment of severity of primary hypothyroidism at presentation and evaluation of the causes of delay in diagnosis in 86 patients was done from December 2012 to November 2013 in the Department of Medicine, MGM Medical College, Indore, MP, India.Results: Illiterate patients had significantly (p value 0.002) higher TSH values at presentation. 34.8% of patients presented as severe hypothyroidism with TSH value >100 mIU/L. Delay of as much as 7 years was noted. Majority of patients had a delay of around 1 to 3 years in diagnosis. Only 4.6% patients were diagnosed without any delay due to high level of suspicion at presentation.Conclusions: Due to non-specific symptomatology of hypothyroidism diagnosis is often delayed. Therefore, high index of suspicion is required at the physician抯 level and test of thyroid function is available at subsided cost therefore it should be offered to all such patients.

Coma mixedematoso como presentación de hipotiroidismo / Myxedema coma as presentation of hypothyroidism

Resumen Se presenta un caso de una paciente de 69 años de edad y sin antecedentes personales o familiares de patología tiroidea alguna, que asiste con un estado convulsivo de aparición súbita, de hemicuerpo derecho y relajación esfinteriana, asociado, además, a trastornos del estado de conciencia, bradicardia, bradipnea y edema de difícil Godet en miembros inferiores. Los exámenes complementarios mostraron acidosis respiratoria, hiposecreción de T4 y elevación de la hormona estimulante de la tiroides por retroalimentación negativa. Estos resultados corroboraron el diagnóstico presuntivo de coma mixedematoso. Se emprendió el tratamiento hormonal correspondiente con levotiroxina, al cual respondió satisfactoriamente y fue egresada a los 24 días de su ingreso, pendiente de valoración por el especialista de endocrinología.

Abstract We present the case of a 69-year-old female patient with no personal or family history of any thyroid disease, who attends with a convulsive state of sudden onset, right hemibody and sphincter relaxation, also associated with disorders of the state of consciousness, bradycardia, bradypnea and edema of difficult godet in lower limbs. Complementary analyses showed respiratory acidosis, hyposecretion of T4 and elevation of the thyroid stimulating hormone by negative feedback. These results corroborated the presumptive diagnosis of myxedema coma. The corresponding hormonal treatment with levothyroxine was undertaken, to which it responded satisfactorily and was discharged 24 days after admission, pending evaluation by the endocrinology specialist for an outpatient hormone replacement therapy.

Coma mixedematoso / Myxedema coma

El hipotiroidismo es una enfermedad frecuente, de diagnóstico y tratamiento simples. Si no es detectada a tiempo puede progresar a la forma más grave conocida como coma mixedematoso. El término "coma mixedematoso" es considerado generalmente engañoso, ya que la mayoría de los pacientes no se presenta inicialmente en estado de coma. La progresión típica es la letargia, evolucionando al estupor y eventualmente al coma, con insuficiencia respiratoria e hipotermia. Es relativamente infrecuente, afecta fundamentalmente a mujeres ancianas, y a menudo ocurre en invierno. Esta entidad debe ser considerada una forma de hipotiroidismo descompensado, desencadenada a partir de una variedad de enfermedades o condiciones no tiroideas que provocan un compromiso sistémico generalizado de extrema gravedad, con desenlace fatal de no mediar un diagnóstico precoz y un tratamiento intensivo.

Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.

Coma mixedematoso en hombre de 74 años: reporte de caso con revisión narrativa / Myxedema coma in a 74 year old man: case report and narrative review

Las células foliculares de la glándula tiroides producen las hormonas tiroxina y triyodotironina, reguladas por la hormona tirotrópica de la hipófisis anterior o tiroestimulante. El coma mixedematoso es definido como un hipotiroidismo profundo que se caracteriza por alteraciones de la conciencia que van desde letargia, estupor y coma al cual se asocia hipotermia, hipoglucemia, convulsiones, hipotensión arterial y manifestaciones de un hipotiroidismo descompensado. La causa o factor desencadenante puede prevenirse si existe diagnóstico previo de hipotiroidismo primario con tratamiento sustitutivo de hormonas tiroideas bien establecido o bien, si en ausencia de diagnóstico éste se sospecha y se trata adecuadamente. Constituye una urgencia médica de mortalidad elevada, donde los factores medioambientales como el frío, infecciones severas e intoxicaciones medicamentosas son importantes factores desencadenantes. Se presenta el caso de un adulto mayor de 74 años, de sexo masculino, sin antecedentes de enfermedad tiroidea que ingresó en Sala de Medicina Interna del Hospital Enrique Cabrera, Habana, Cuba, en el mes de diciembre de 2011, con signología clínica y de laboratorio propias de la hipofunción tiroidea, siendo confirmado coma mixedematoso y con evolución desfavorable.

The follicular cells of the thyroid gland produce thyroxine and triiodothyronine hormones, as regulated by the thyrotropic hormone of the anterior pituitary, also called thyroid stimulating hormone. Myxedema coma is defined as profound hypothyroidism characterized by impairment of consciousness ranging from lethargy to stupor and coma, associated with hypothermia, hypoglycemia, seizures, hypotension, and manifestations of uncompensated hypothyroidism. The condition can be prevented if diagnosis of primary hypothyroidism is established and thyroid hormone replacement therapy is instituted. It is considered a medical emergency with high mortality rates, where environmental factors such as cold, severe infections and drug poisoning are important triggering factors. We report the case of a 74 year old male adult with no history of thyroid disease who was admitted to the Internal Medicine Ward of the “Enrique Cabrera” Hospital, Havana, Cuba, in December 2011, with clinical and laboratory signs of thyroid hypofunction. Myxedema coma was confirmed and patient course was untoward.

A Case of Myxedema Coma Presenting as a Brain Stem Infarct in a 74-Year-Old Korean Woman

Myxedema coma is the extreme form of untreated hypothyroidism. In reality, few patients present comatose with severe myxedema. We describe a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. She presented to the hospital with alteration of the mental status, generalized edema, hypothermia, hypoventilation, and hypotension. Initially her brain stem reflexes were absent. After respiratory and circulatory support, her neurologic status was not improved soon. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism. A high index of clinical suspicion can make a timely diagnosis and initiate appropriate treatment. We report this case to alert clinicians considering diagnosis of myxedema coma in patients with severe decompensated metabolic state including mental change.

A case of myxedema coma treated with a large oral dose of levothyroxine / 대한내과학회지

Myxedema coma is the most extreme form of hypothyroidism and manifests as central nervous system dysfunction, defective thermoregulation, and cardiopulmonary decompensation. The curative treatment is based on the administration of thyroid hormones, but the dose and route of administration remain controversial. Here, we report a case of myxedema coma that was treated successfully with a large oral dose of levothyroxine

Coma mixedematoso y midazolam: Reporte de caso / Myxedema coma and midazolam: A case report

Se reporta el caso de un paciente varón sin antecedente previo de patología tiroidea que ingresó por coma mixedematoso y desarrolló insuficiencia respiratoria después de la administración endovenosa de midazolam. Tenía 55 años de edad, y una enfermedad de dos semanas caracterizado por letargia, debilidad, hiporexia y cefalea. Los análisis de laboratorio mostraron anemia, hiponatremia severa y niveles elevados de transaminasas y creatinquinasa. TSH elevada y T4 y T3 en niveles muy bajos. Se inició tratamiento con levotiroxina, corticoides endovenosos y solución hipertónica de cloruro de sodio. La evolución fue mala, se colocó un catéter venoso central bajo sedación con midazolam endovenoso para monitoreo hemodinámico, luego del cual, el paciente desarrolló insuficiencia respiratoria, mayor compromiso del sensorio y falleció. En pacientes con hipotiroidismo, el metabolismo del midazolam esta alterado y puede causar insuficiencia respiratoria.

A 55-year-old man with a two weeks history of lethargy, weakness, hyporexia and headache. Laboratory tests showed anemia, severe hyponatremia, elevated creatine kinase and transaminasas levels, elevated TSH and very low levels of T4 and T3. Diagnosis of myxedema coma was established and treatment was begun with oral levothyroxine, IV corticosteroids and hypertonic saline. Because of worsening clinical status a central venous catheter was placed without complications with IV midazolam as sedative. Patient developed respiratory insufficiency, decreased mental status and died. Metabolism of midazolam is impaired, and its use can cause respiratory insufficiency in the setting of hypoventilation associated with hypothyroidism.