ABSTRACT
O coma mixedematoso eÌ uma emergeÌncia endocrinoloÌgica rara e consiste na máxima expressão do hipotireoidismo, com alta mortalidade por suas complicações hemodinâmicas e ventilatórias, podendo ser agravadas por distúrbios da coagulação. Relatamos o caso de uma paciente diagnosticada com coma mixedematoso e trombo de veia cava superior. Buscamos salientar os distúrbios de coagulação frequentes no hipotireoidismo grave, que contribuem para o aumento da mortalidade deste grupo de pacientes. O diagnoÌstico e o tratamento precoce do coma mixedematoso, aliados aÌ instituiçaÌo imediata da terapia para o fenômeno trombótico encontrado, permitiram a evoluçaÌo favoraÌvel do quadro. O relato, juntamente da bibliografia pesquisada, orientou o raciocínio sobre a relação dos distúrbios de coagulação, que ocorrem no hipotireoidismo descompensado. Apesar de poucos relatos, estes distúrbios podem ser frequentes e devem ser pesquisados, pois contribuem com o aumento da mortalidade.(AU)
Myxedema coma is a rare endocrinological emergency, consisting of the highest expression of hypothyroidism with high mortality due to hemodynamic and ventilatory complications, which may be aggravated by coagulation disorders. We report the case of a patient diagnosed with myxedema coma and superior vena cava thrombus. We sought to emphasize the frequent coagulation disorders in severe hypothyroidism, which contribute to increased mortality in this group of patients. The diagnosis and early treatment of myxedema coma, together with the immediate institution of therapy for the thrombotic phenomenon found, allowed the favorable evolution of the condition. The report, together with the literature, has guided the rationale for the influence of coagulation disorders that occur in decompensated hypothyroidism. Despite the few number of reports, these disorders can be frequent and should be investigated because they contribute to the increase in mortality.(AU)
Subject(s)
Humans , Female , Middle Aged , Blood Coagulation Disorders/complications , Superior Vena Cava Syndrome , Coma/complications , Hypothyroidism/complications , Myxedema/complications , Blood Coagulation Disorders/therapy , Coma/diagnosis , Myxedema/diagnosisABSTRACT
Although hypothyroidism is associated with an increased prevalence of psychiatric manifestations, myxedema madness is rarely observed. We report the case of a 62-year-old woman with no prior history of psychiatric disorders, who presented to the emergency department with psychomotor agitation 6 weeks after total thyroidectomy for papillary thyroid cancer. Serum thyroid stimulating hormone (TSH) on admission was 62.9 mIU/L and free T4 was < 0.35 ng/dL, indicating severe hypothyroidism. After ruling out other possible causes, the diagnosis of myxedema madness was considered; hence, antipsychotic drug treatment and intravenous levothyroxine were prescribed. Behavioral symptoms returned to normal within 4 days of presentation, while levels of thyroid hormones attained normal values 1 week after admission. Recombinant TSH (Thyrogen®) was used successfully to prevent new episodes of mania due to thyroid hormone withdrawal in further controls for her thyroid cancer. This case illustrates that myxedema madness can occur in the setting of acute hypothyroidism, completely reverting with levothyroxine and antipsychotic treatment. Recombinant TSH may be a useful tool to prevent myxedema madness or any severe manifestation of levothyroxine withdrawal for the follow-up of thyroid cancer.
Subject(s)
Humans , Female , Middle Aged , Psychomotor Agitation/etiology , Thyroxine/therapeutic use , Thyroid Neoplasms/surgery , Myxedema/complications , Postoperative Period , Psychomotor Agitation/drug therapy , Antipsychotic Agents/therapeutic use , Thyroid Neoplasms/complications , Myxedema/drug therapyABSTRACT
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.
Subject(s)
Humans , Male , Aged , Coma/etiology , Myxedema/complications , Myxedema/diagnosis , Diagnosis, DifferentialABSTRACT
El coma mixedematoso es la forma más severa y profunda del hipotiroidismo. Se presenta con mayor frecuencia en mujeres y ancianos. Entre los factores precipitantes se encuentran: la sepsis, la exposición al frío, los eventos agudos graves, el uso de anestésicos, sedantes o narcóticos, así como la descontinuación del tratamiento sustitutivo con hormonas tiroideas, entre otros. El diagnóstico clínico se realiza por la presencia de síntomas y signos característicos de un hipotiroidismo severo, con hipotermia y alteraciones de la conciencia. Apoyan este diagnóstico los hallazgos de laboratorio: hiponatremia, hipoxemia, hipercapnia, alteraciones hemoquímicas y el aumento de la tirotropina por la disminución de las hormonas tiroideas en el caso de la enfermedad primaria. El tratamiento se debe realizar en una unidad de cuidados intensivos, con monitorización, medidas de soporte respiratorio y cardiovascular, calentamiento corporal interno, hidratación, corrección de la hipotensión y de los trastornos electrolíticos. Se administrarán, además, glucocorticoides, antibióticos de amplio espectro y hormonas tiroideas. La evolución depende de la demora en el inicio del tratamiento, la edad, las comorbilidades, la hipotermia persistente y las complicaciones asociadas(AU)
Myxedema coma is the most severe and deepest form of hypothyroidism. It occurs more often in the women and the elderly. Among the unleashing factors found are sepsis, exposure to cold, acute severe events, use of anesthetic drugs, sedatives or narcotics as well as the interruption of the replacement treatment with thyroid hormones, among others. The clinical diagnosis is based on the presence of symptoms and signs that are characteristic of severe hypothyroidism, with hypothermia and altered consciousness. This diagnosis is also supported by the lab findings: hyponatremia, hypoxemia, hypercapnia, hemochemical alterations and the rise of thyrotropin due to the decrease of thyroid hormones in the case of the primary disease. The patient should be treated in an intensive care unit, by using monitoring, respiratory and cardiovascular support, internal body heating, hydration, correction of hypotension and control of electrolytic disorders. Additionally, glycocorticoids, broad-spectrum antibiotics and thyroid hormones should be administered. The progression of the disease depends on the delay in starting the treatment, the age, the comorbidities, the persistent hypothermia and the associated complications(AU)
Subject(s)
Female , Aged , Hypothyroidism/complications , Hypothyroidism/diagnosis , Myxedema/complications , EmergenciesABSTRACT
Cognitive impairment among patients with hypothyroidism is a well known condition, but its pathophysiology is not fully understood. Thyroid hormones may influence several processes in the brain, including cerebral perfusion, cerebral metabolism and neurotransmitter activity and could partially explain the neuropsychiatric manifestations of hypothyroidism. Acute psychosis is rare as a manifestation of hypothyroidism, but is potentially reversible. We report a 37 years old female without a previous history of psychiatric illness, presenting with an acute psychosis that required hospital admission. Her serum TSH was 122.2 uUI/mL (normal 0.3-4.2 uUI/mL), her total T4 was 1.1 ug/dL (normal 4.6-12 ug/dL), her free T4 was 0.1 ng/dL (VN 0.9-1.7 ng/dL), her total T3 was 30.5 ng/dlL (normal 84-201 ng/dL), and her antiTPO antibodies were 5464 UI/mL (normal < 12 UI/mL). Thyroid substitution was started with an important remission of psychotic symptoms. One month later, anti-psychotic medication was discontinued.
Subject(s)
Humans , Adult , Female , Hypothyroidism/complications , Myxedema/complications , Psychotic Disorders/etiology , Antipsychotic Agents/therapeutic use , Hypothyroidism/physiopathology , Hypothyroidism/psychology , Hypothyroidism/drug therapy , Synapses , Treatment Outcome , Thyroxine/therapeutic use , Psychotic Disorders/drug therapyABSTRACT
Myxedema is the cause of ascites in less than 1 per cent of new-onset ascites cases, where as only 4 per cent of patients with hypothyroidism present ascites. When ascites is the first manifestation of thyroid insufficiency, there is usually a delay in diagnosis. We report here a case of myxedema ascites occuring in a patient with alcoholic cirrhosis, that was first thought to be the cause of the ascites, and review the features of 48 cases previously reported. Some clinic and analytical findings that have been commonly reported, are the prompt response (with resolution of ascites) to thyroid replacement treatment, a high total protein concentration in ascitec fluid, white moderate white blood cell counts and a lymphocyte predominance. Serum-ascites albumin gradient has been postulated to be high in myxedema ascites, but we believe this has been studied in too few cases thus far, to be conclusive.
Subject(s)
Humans , Male , Middle Aged , Ascites/etiology , Liver Cirrhosis, Alcoholic/complications , Myxedema/complications , Ascites/drug therapy , Hormone Replacement Therapy/methods , Myxedema/diagnosis , Myxedema/drug therapy , Thyroxine/therapeutic useABSTRACT
The lesser known manifestations of myxoedema encompass a wide spectrum of neurologic, psychiatric, endocrinologic and autoimmune pathology that mask obvious clinical diagnosis. Interesting head and neck presentations are discussed. The relationships with the Pendred and Down syndromes raise hereditary and genetic considerations.
Subject(s)
Humans , Myxedema/complications , Nervous System Diseases/etiologyABSTRACT
Se informa el caso de una paciente de 35 años de edad con mixedema y derrame pericárdico importante, que presentó taponamiento cardiaco durante el tratamiento con hormonas tiroideas. El ecocardiograma y la valoración clínica y radiológica periódica mostraron la desaparición del taponamiento y una disminución progresiva del derrame. Se considera que los casos en los que la repercusión clínica del taponamiento no sea importante el tratamiento puede ser exclusivamente médico