Navigating the Storm: Myxedema Coma-Induced Cardiomyopathy Culminating in Refractory Cardiogenic Shock.

Myxedema coma is a rare and life-threatening consequence of severe hypothyroidism, often precipitated by physiologic stressors. While cardiac manifestations are common, they are typically reversible with prompt treatment. Here, we report a case of a 23-year-old male with untreated hypothyroidism who presented with myxedema coma-induced cardiomyopathy leading to refractory cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and, ultimately, orthotopic heart transplantation (OHT). Our case highlights a rare occurrence of refractory shock necessitating mechanical support as a bridge to a cardiac transplant. We emphasize early recognition, aggressive management, and a low threshold to escalate care to mitigate the high mortality associated with myxedema coma.

Increased incidence of myxedema coma during the COVID-19 pandemic and in the post pandemic era: a single-center case series.

The COVID-19 pandemic was a major challenge for all health care employees, but it was also difficult for patients to gain access to health care services. Myxedema coma (MC) is an extremely rare but potentially fatal endocrine emergency. The aim of the study was to report an increased incidence of life-threatening myxedema coma that occurred in relation to the COVID-19 pandemic. In this paper, we report a cohort of 11 patients with MC who were treated at the University Hospital in Krakow, Poland, in the period from 2015 to 2023. Only 1 case of MC was recorded in the period from 2015 to 2019, and, in the same area, 10 cases of MC were recorded after the start of COVID-19 pandemic until present. Hypothyroidism was diagnosed de novo in 2 (18%) patients; the remaining patients were severely hypothyroid due to therapy non-compliance. Nine patients had primary hypothyroidism, and 2 had central hypothyroidism. Besides longstanding hypothyroidism, an additional precipitating factor for MC was identified in 4 (36%) of the patients. Due to the inaccessibility of parenteral levothyroxine, patients were treated with oral, mostly liquid, form of levothyroxine. The mortality rate in this cohort was 27.2%. In conclusion, the increase of the incidence of MC, which is a life-threatening complication of inadequately treated hypothyroidism, during the COVID-19 pandemic, when resources were limited, and in the post-pandemic era, underlines the importance of adequate communication with patients and of long-term availability of primary care for patients with thyroid disease.

Cardiac Pre-tamponade Secondary to Generalized Myxedema Due to Neglected Hashimoto's Thyroiditis in a Child With Down Syndrome.

Down syndrome (DS) is the most common chromosomal disorder in live-born infants, often associated with intellectual disability and various medical conditions, including thyroid dysfunction. Hashimoto's thyroiditis (HT), an autoimmune subtype, is a leading cause of acquired hypothyroidism in DS children. Severe hypothyroidism can precipitate myxedema, a critical condition linked to complications like pericardial effusion and cardiac tamponade. This case study presents a nine-year-old male with DS who was admitted for acute respiratory distress exhibiting classic signs of myxedema. Initial investigations revealed severe hypothyroidism and significant pericardial effusion. Surgical pericardiotomy drained 800 mL of fluid, confirming myxedema secondary to HT. Levothyroxine therapy led to progressive improvement, resolving myxedematous infiltrate and associated symptoms within a month. Follow-up at 12 months demonstrated sustained improvement with normalized thyroid function and no clinical disease activity. This case highlights an atypical presentation of HT in a DS child with cardiac pre-tamponade.

Assessing the relationship between psoriasis and thyroid dysfunction through two sample MR analysis.

BACKGROUND: The association between psoriasis and hyperthyroidism/hypothyroidism remains inconclusive, with conflicting findings in prior studies. OBJECTIVES: This study employs Mendelian randomization methods to assess the potential relationship. METHODS: Given the inability to accurately observe the link between psoriasis and thyroid dysfunction, we prioritized utilizing known genetic variants to investigate the potential impacts of the disease.We analyzed data from genome-wide association studies (GWASs), FinnGen, and UK Biobank to extract information on psoriasis, hyperthyroidism, and hypothyroidism. Three MR approaches (MR Egger, weighted median, and inverse variance weighted) were used to scrutinize the causal link. RESULTS: Our analysis revealed no correlation between psoriasis and hyperthyroidism/hypothyroidism. However,  vulgar psoriasis and guttate psoriasis were associated with hypothyroidism/myxedema (IVW odds ratio (OR) = 1.00, 95% confidence interval (CI) = 1.00-1.00, P = 2.53E-03), and Graves' disease (IVW OR = 0.86, 95% CI = 0.72-1.01, P = 4.75E-02).In a subsequent analysis, we observed that hypothyroidism with mucinous edema showed no correlation with Graves' disease in the opposite(P = 9.33E-01). CONCLUSION: This MR analysis suggests no association between psoriasis and thyroid dysfunction, but highlights associations of vulgar/guttate psoriasis with hypothyroidism/myxedema and Graves' disease. In clinical practice, diagnosing guttate psoriasis requires vigilance for associated risks from hypothyroidism and Graves' disease. For patients with both vulgar psoriasis and hypothyroidism, careful monitoring for mucinous edema is crucial, as it may signal a hypothyroid crisis.

Untreated Primary Hypothyroidism Manifesting as Cardiac Tamponade.

Hypothyroidism is a condition characterized by low thyroid hormone levels that can affect multiple organ systems with varying symptomatology. Common cardiac manifestations of hypothyroidism include bradycardia and decreased cardiac output. Pericardial effusion can also occur as a result of the condition and rarely can progress to cardiac tamponade. Patients with cardiac tamponade occurring as a result of underlying hypothyroidism can present atypically compared to those experiencing cardiac tamponade due to other causes. Patients with cardiac tamponade as a result of underlying hypothyroidism may present as minimally symptomatic with stable vital signs. Close monitoring of patients with pericardial effusions with underlying hypothyroidism is essential to permit early diagnosis and treatment of the condition. We outline the case of a 73-year-old male presenting with cardiac tamponade due to underlying hypothyroidism necessitating an urgent pericardial window.

Thyroid Troubles: A Case of Hypothyroidism-Associated Recurrent Massive Pleural Effusion.

Pleural effusions can be secondary to several different etiologies. Sometimes, they can be related to hypothyroidism. We present a case of massive pleural effusion resulting from hypothyroidism. A 75-year-old male with a history of liver cirrhosis, hypothyroidism, and medication non-adherence presented to the emergency department (ED) with shortness of breath and altered mental status. Physical exam and chest imaging were consistent with right-sided pleural effusion. Effusion was exudative. Multiple recurrences complicated the hospitalization despite thoracentesis and pleurodesis. Labs revealed hypothyroidism, and finally, the patient was started on hormone replacement, resulting in the resolution of the effusion. Pleural effusion is a rare manifestation of hypothyroidism, thought to be mediated by vascular endothelial factors. Pleural fluid analysis shows both exudative and transudative patterns. Hormonal replacement is the mainstay of treatment. Clinicians need to be aware of the rare etiologies of pleural effusion. Depending on the patient's presentation, due work-up should be done to ensure a timely diagnosis and management.

Severe Post-partum Hypothyroidism Triggering Psychogenic Non-epileptiform Seizures, Myopathy, and Myxedema Coma.

This study details the development of severe post-partum hypothyroidism exacerbating psychogenic non-epileptiform seizures (PNES) and culminating in myxedema coma. A 29-year-old female with a history of anxiety, attention-deficit/hyperactivity disorder (ADHD), and post-partum depression presented with confusion, aphasia, and severe bilateral leg cramping five months following vaginal delivery. Initial laboratory tests indicated elevated creatine kinase (CK) levels, suggestive of non-traumatic rhabdomyolysis. Subsequent seizure-like episodes and the absence of epileptiform activity on the electroencephalogram (EEG) raised suspicions of PNES. Further investigation upon readmittance to the hospital revealed a thyroid-stimulating hormone (TSH) level of 216 mIU/L (range: 0.4-4.0 mIU/L), free thyroxine (T4) level of 0.2 ng/dL (range: 0.8-1.8 ng/dL), and a CK level of 2083 U/L (range in females: 30-150 U/L), indicating severe hypothyroidism with myopathy. Reintroducing levothyroxine (Synthroid), which was previously discontinued during pregnancy, rapidly resolved her symptoms, supporting suspicions that her non-epileptic seizures and myopathy were both caused by her underlying severe post-partum hypothyroidism. She was maintained on levothyroxine with only one seizure-like episode following hospital discharge. This case illustrates the importance of a thorough endocrine assessment in patients with neuropsychiatric presentations, particularly in the peripartum period. It highlights the potential for severe thyroid dysfunction to manifest as PNES, emphasizing the complexity of diagnosing and managing such cases. The findings advocate for a multidisciplinary approach to evaluating post-partum females with neurological and psychiatric symptoms and provide evidence for the link between thyroid disorders and PNES, advocating for a nuanced approach in similar clinical scenarios.

Graves' disease thyroid dermopathy: a case report.

BACKGROUND: Graves' disease is the autoimmune activation of the thyroid gland causing diffuse enlargement and hyperfunction of the gland. Manifestations of Graves' disease are multisystemic and include thyroid orbitopathy; pretibial myxedema, also referred to as thyroid dermopathy; and thyroid acropachy, described as a severe form of thyroid dermopathy. Our paper focuses on an atypical case of thyroid dermopathy. CASE PRESENTATION: An 11-year-old Saudi male presented with a prominent diffuse goiter and exophthalmos. Investigations were consistent with a diagnosis of Graves' disease. The physical exam showed diffuse, non-pitting swelling of the ankle and penis, mimicking a lymphatic malformation. Further, multiple nodules were found on the hands and feet. Treatment of the nodules with cautery resulted in more severe nodules. CONCLUSION: This report describes rare presentations of thyroid dermopathy mimicking lymphatic malformation. The Koebner phenomenon can explain this patient's atypical presentations. Intralesional injections of triamcinolone and total thyroidectomy showed clear improvement.

Myxedema Psychosis: Diagnostic Challenges and Management Strategies in Hypothyroidism-Induced Psychosis.

Myxedema psychosis (MP), a rare psychiatric manifestation of hypothyroidism, presents significant diagnostic and therapeutic challenges. This case report details the presentation, diagnosis, and successful management of a 60-year-old woman with MP, who was initially admitted to the psychiatric department for new-onset psychosis following the cessation of hormone replacement therapy after a subtotal thyroidectomy performed 20 years prior. Despite the rarity of psychosis as an initial presentation of hypothyroidism, this case underscores the critical importance of considering endocrine disorders in the differential diagnosis of unexplained psychotic symptoms. The clinical findings included a polymorphic delusional system and auditory hallucinations, without significant abnormalities on magnetic resonance imaging. Elevated thyroid-stimulating hormone (TSH) levels confirmed hypothyroidism, leading to the diagnosis of MP. Treatment with l-thyroxine resulted in complete resolution of symptoms in three weeks, highlighting the efficacy of hormone replacement therapy. This case contributes to the limited literature on MP and echoes the need for awareness among clinicians to ensure timely and accurate diagnosis and treatment.

Supraglottic Myxedema Presenting as a Complication of Hypothyroidism: A Case Report.

Myxedema is a medical emergency with high mortality rates if not treated aggressively. Here, we present a middle-aged female with complaints of generalized body swelling for one year, shortness of breath, hoarseness of voice, neck swelling, and cough for 20 days. The patient was diagnosed to be having severe hypothyroidism with polyserositis. Contrast-enhanced computed tomography (CECT) of the neck and thorax revealed extensive soft tissue edema causing airway narrowing, bilateral pleural effusion, moderate pericardial effusion, and features of atypical pneumonia. The patient was started on levothyroxine and antibiotics as per cultures to which she had initially improved; however, she developed ventilator-associated pneumonia leading to sepsis, acute respiratory distress syndrome followed by refractory type 1 respiratory failure and succumbed.

Pretibial myxedema in Grave's disease: A case report and treatment review of the literature.

Key Clinical Message: Pretibial myxedema is a rare skin lesion in Grave's disease, which required topical glucocorticoid administration in long-term treatment. The patient's lesion has shrunk and become flatter than before treatment. Abstract: We present a case of biopsy-verified pretibial myxedema in a 70-year-old male patient with diagnosed hyperthyroidism and no prior history of Graves' disease. Topical corticosteroid and antithyroid drug administration led to successful resolution of the skin lesions. This case emphasizes the importance of considering pretibial myxedema even in atypical presentations of Graves' disease and underscores the value of prompt treatment.

Clinical Features and Outcomes of Myxedema Coma in Patients Hospitalized for Hypothyroidism: Analysis of the United States National Inpatient Sample.

Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.

Concurrent pretibial myxedema and thyroid eye disease following mRNA COVID-19 vaccine in a patient with history of Graves' disease.

A 70-year-old female had a history of thyroid surgery for benign nodules and Graves' disease. Following mRNA COVID-19 vaccination, she presented Graves' orbitopathy and pretibial myxedema. Symptoms of thyroid eye disease and thyroid dermopathy improved after 500-mg methylprednisolone infusions.

Teprotumumab for Treatment of Pretibial Myxedema.

Pretibial myxedema (PTM), also called thyroid dermopathy, is a dreaded and potentially debilitating manifestation of thyroid disease, more commonly Graves' disease, which can occur at any time over the course of the disease. No substantial long-term therapies have been able to target the condition, and management has typically been supportive (eg, compression socks, weight loss), with courses of moderate-intensity steroids. Teprotumumab has been approved for the management of thyroid eye disease (TED), and it is believed that the 2 share a similar pathophysiology likely related to type 1 insulin-like growth factor receptor, which may explain why some patients have also experienced improvement in PTM. Here we present a patient who received 8 doses of teprotumumab for TED who, over the course of management and into follow-up, experienced significant improvement in her pretibial myxedema. The patient noted considerable improvement in quality of life and ability to perform daily activities. We present this case to consider further investigation into the utilization of teprotumumab for thyroid disease-related PTM in patients with impaired quality of life.

Optic Neuropathy Following Acute Decompensated Hypothyroidism (Myxedema Crisis).

Myxedema crisis (MC) refers to an unusual state of regulatory dysfunction precipitated by uncontrolled hypothyroidism. The pathogenic consequences of MC are broad and may contribute to significant bodily decompensation across multiple organ systems. However, shock-induced ischemic optic neuropathy (SION) in this setting has not been reported previously. Here, we present the case of a 76-year-old female with presumed bilateral optic neuropathy following abdominal surgery. The patient experienced a prolonged and complicated postoperative course in which she remained off supplemental levothyroxine. Subsequently, her clinical status deteriorated until she met diagnostic criteria for acute decompensated hypothyroidism (MC). Upon awakening from a comatose state, she reported significant vision loss. A neuro-ophthalmologic evaluation later confirmed significant constriction of her visual fields, optic disc pallor, and global retinal nerve fiber layer loss consistent with nonarteritic ischemic optic neuropathy.

[Pretibial myxedema after Graves' disease: A differential diagnosis of lymphedema]. / Myxœdème prétibial pseudo-tumoral après une maladie de Basedow : un diagnostic différentiel du lymphœdème.

INTRODUCTION: Pretibial myxedema is a rare manifestation of Graves' disease, and pseudotumoral forms may be confused with lower limb lymphedema. OBSERVATIONS: We reported 3 cases of pretibial myxedema in 2 women and 1 man, aged 72, 66, and 49 years, treated for Graves' disease 3, 25 and 32 years previously. Two patients were active smokers. Lymphedema diagnosis of the lower limbs was suspected in the presence of bilateral pseudotumoral lesions of the feet, toes and ankles and the presence of a Stemmer's sign (skin thickening at the base of the 2nd toe, pathognomonic of lymphedema). Lymphoscintigraphy in one case was normal, not confirming lymphedema. CONCLUSION: Pretibial pseudotumoral myxedema is a differential diagnosis of lower limb lymphedema. This diagnosis is confirmed by questioning the patient about preexisting Graves' disease, the underlying etiology, to decide the appropriate treatment and to encourage cessation of smoking, which is a risk factor for pretibial myxedema.

A Rare Case of Myxedema Coma Precipitated by a Single Dose of Haloperidol in a Patient With Paranoid Schizophrenia.

Myxedema coma is a rare and potentially life-threatening condition that occurs when severe hypothyroidism is untreated or inadequately managed. It is characterized by a rapid drop in mental status, hypothermia, respiratory failure, hypotension, and other symptoms of severe metabolic dysfunction. The condition primarily affects older women with a history of thyroid dysfunction but can occur in any age or gender group. A common trigger for this condition is seen with a drop in atmospheric temperatures or during the cold winter months. However, a rare, poorly documented trigger is recent antipsychotic use in severe hypothyroid states. The diagnosis of myxedema coma requires prompt recognition and treatment, as delays can result in significant morbidity and mortality which is the objective of this case report.

Myxedema Coma and the Heart: Would You Miss the Signs?

Myxedema Coma (MC) is a life-threatening medical emergency that occurs as a severe complication of untreated or poorly managed hypothyroidism. Prompt diagnosis is crucial as the condition can rapidly deteriorate and lead to life-threatening complications. Timely treatment of myxedema coma with intravenous levothyroxine is the cornerstone of treatment, along with glucocorticoids to support adrenal function. This condition is associated with cardiovascular manifestations that contribute to its high mortality rate. The heart in hypothyroidism typically shows reversible dysfunction that can be corrected with hormonal supplementation, and in some cases, requires inotropic and aminergic support. This case involves a patient who was admitted to the intensive care unit with suspected MC, and necessitated life-saving hormonal and cardiovascular support to manage the condition.

Impacted Wisdom Teeth Removal on a Patient with Primary Hypothyroidism (Hashimoto Disease).

Thyroid gland dysfunctions can adversely affect patients' systemic health and well-being. Thyroid disease is the most common endocrine disorder. Recognizing early signs and symptoms of hypothyroidism is crucial in the early diagnosis of hypothyroidism. Oral health care providers must obtain comprehensive medical records from patients with hypothyroidism before dental treatments.