Myxoedema Coma Precipitated by Diabetic Ketoacidosis and Septic Shock: a Case Report

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Abstract

Myxoedema coma (or myxoedema crisis) is a severe and potentially fatal form of decompensated hypothyroidism with an underlying cause. A low index of suspicion and a search for triggering factors should be the first step in dealing with the condition at an early stage. Myxoedema coma should be suspected in patients who present with hypothermia, altered mental status, and coma, even if hypothyroidism has not previously been recognized. The symptoms of hypothyroidism decompensation may mistakenly be attributed to its precipitating factors, which may include sepsis, cardiac failure, myocardial infarction, cerebrovascular accident, anaesthetic, sedatives, antidepressant medications, or metabolic and electrolyte abnormalities. Here, we present a case of myxoedema coma with two major underlying precipitating causes: septic shock and diabetic ketoacidosis.

Keywords: DKA, Hypothyroidism, Myxedema Coma, Septic Shock

Introduction

Myxoedema coma is a severe and life- threatening form of decompensated hypothyroidism with an underlying precipitating factor. It can present with altered mental status, hypothermia, bradycardia, respiratory failure, and hyponatremia. Mortality rates may be as high as 25–60%, even with the best possible treatment [1-3].

Rizq Badawi , Ahmed Alsuliamani , Abdullah Alhejaili are with the Department of Emergency Medicine, King Fahd Medical City, Riyadh, Saudi Arabia (Emails: rizqbadwi@gmail.com, ahmed.alsulaimani95@gmail.com, Ab.h.1@hotmail.com), Eyad Alnemer is with the Emergency/Critical Care, Ministry of Health, Medina, Saudi Arabia. (Email: Eyadmn@hotmail.com) DOI: 10.52609/jmlph.v4i2.128

A low index of suspicion and a search for precipitating factors should be the initial step in dealing with myxoedema coma at an early stage [4]. Triggers may include poor medication compliance, thyroidectomy, acute events (including infection and cardiac infection among other stresses), and medical treatments that cause loss of thyroid homeostasis [5]. The mainstay of treatment includes hydrocortisone, intravenous liothyronine, levothyroxine, electrolyte correction, supportive therapies, and treating any underlying precipitant such as infection, surgery, or trauma [1,6]. Suspected myxoedema coma cases should receive intravenous hydrocortisone while awaiting laboratory results, as any delay can be life-threatening. The condition should ideally be managed in the intensive care unit (ICU) with pulmonary and cardiovascular support [7,8]. Here we report a case of myxoedema coma presenting with two main underlying precipitating factors: septic shock and diabetic ketoacidosis (DKA).

Case Presentation

The patient was a 42-year-old male with a history of Down syndrome, epilepsy, and type 1 diabetes mellitus (T1DM). One year prior, he had required a 28-day admission to the ICU where he received treatment for pneumonia, ultimately recovering without complications. In the current admission, he was transferred from a primary hospital to the emergency department (ED) on October 18, 2023 having been intubated for septic shock secondary to pneumonia and DKA . Prior to his transfer, the patient had experienced three days of fever, cough, sore throat, decreased level of consciousness, and loss of appetite. Upon arrival at the Emergency Department, the patient was intubated for mechanical ventilation using a 7.5 mm endotracheal tube (ETT)

positioned at a depth of 22 cm. Ventilation was provided in the assist-control volume control (AC/VC) mode, with the following parameters: fraction of inspired oxygen (FiO2) 100%, tidal volume (Vt) 480 mL, positive end-expiratory pressure (PEEP) 8 cmH2O, and a respiratory rate of 20 breaths per minute. Oxygen saturation (SpO2) was recorded at 92%, and bilateral inspiratory crackles were noted. The patient was afebrile, with a blood pressure of 118/80 mm Hg, heart rate of 126 beats per minute, and random blood glucose level of 581 mg/dl. Venous cannulae (20 gauge) were secured, and the patient received ongoing sedation with fentanyl (100 mcg per hour) as well as norepinephrine (30 mcg per hour). He was following a protocol for the treatment of DKA, involving regular doses of insulin (7 IU), as well as potassium chloride at a dose of 15 meq in 500 ml fluid, administered intravenously at a rate of 250 ml per hour. Additionally, he had an indwelling urinary catheter (size F12 silicone), connected to a collection bag. However, despite this setup, only minimal urinary output was observed.

Management in the Emergency Department: The patient was connected to a cardiac monitor and a bolus of 1000 ml normal saline was administered. Intravenous medications were also administered, including a single dose of 5 mg midazolam followed by a continuous infusion at 5 mg per hour, and an increase in fentanyl infusion to 200 mcg per hour. Hydrocortisone 50 mg and meropenem 1000 mg were also administered. A right femoral central venous catheter (size 7) was inserted at a depth of 20 cm; vasopressin infusion was initiated at a rate of 0.04 IU per minute; and a 65-cm nasogastric tube (size F14) was inserted and confirmed via auscultation to be patent and intact. A urinary output of 200 ml was noted, which was amber in colour. Chest X-ray revealed bilateral infiltrations, while urine dipstick analysis showed significant levels of protein, glucose, ketones, and blood. Table 1 illustrates the patient’s venous blood gases along with the chemistry panel. The patient was admitted for DKA and septic shock secondary to pneumonia and showed no

As his TSH levels dropped, the patient started to stabilize vitally, regained consciousness, and was extubated. Another important tool in the management of severe hypothyroidism is glucocorticoids [15,16], due to the risk of adrenal insufficiency that accompanies this condition. In our case, a dose of hydrocortisone was given in the ED. In summary, myxoedema can easily be misdiagnosed, especially when symptoms are masked by other critical conditions ― in the case of our patient, septic shock complicated by DKA. Thus, suspicion should be raised even where there is no known history of hypothyroidism. While the mortality of myxoedema remains high, early recognition and treatment can play a major role in improving patient outcomes.

Conclusion

Myxedema coma should be suspected in patients presenting with hypothermia, altered mental status, and coma, even where there is no history of hypothyroidism, and particularly in those at greater risk for the condition, such as, in our case, people with Down syndrome. Many factors can trigger myxedema, including cold exposure, sepsis, DKA, and cardiogenic shock. Those at high risk should be investigated, given that mortality is high even with the appropriate management.

Table 1. Venous blood gases and chemistry panel
TestResult
Venous BloodGases
- pH7.12
- Partial pressure of carbon dioxide (pCO2)47 mmHg
- Bicarbonate (HCO3)15 mmol/L
- Lactate4 mmol/L
- Base deficit-16 mmol/L
CBC
- White blood cells (WBC)8 x 10^3/μL
- Haemoglobin (Hgb)14 g/dL
ChemistryPanel
- Creatinine235 U/L
- Urea8 mmol/L
- Potassium3.8 mmol/L
- Sodium144 mmol/L
Urine Dipstick
- Protein++
- Glucose+++
- Ketones+++
- Blood++
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improvement within the first 48 hours ofseptum (IVS) were intact. The pericardium
admission. Severe metabolic acidosis,appeared normal.
hyperkalaemia, oliguria, and pre-renal acuteA few days later, the patient showed
kidney injury (AKI) secondary to septic shockimprovement in terms of mechanical ventilation
all manifested simultaneously. Continuous renalparameters and vasopressor requirements. He
replacement therapy (CRRT), anti-was extubated and received dexamethasone 8
hyperkalaemia treatment, and furosemidemg twice daily for 24 hours. He showed
infusion were initiated. Despite theseimprovement, with a Glasgow Coma Scale
interventions, the patient remained hypotensive.(GCS) score of 13 out of 15. He continued to
An arterial line was inserted and vasopressorsimprove over the following days; after 2 days he
were maximized, aiming for a 1-L negative fluidwas placed on a nasal cannula at 4 litres per
balance.minute (LPM).
At that point, myxoedema coma was the mainThe patient received a loading dose of
concern, especially when the thyroid-intravenous levothyroxine (LT4) 200 mcg,
stimulating hormone (TSH) level came backfollowed by a maintenance dose of 150 mcg,
very high; thus, T3 and T4 tests were ordered.initiated on October 19, 2023. His TSH levels
The patient was not known to have suffereddecreased from 216 upon initiation, to 41 on 25
from hypothyroidism before (his history wasOctober, 6 days later. This drop of >50 % in less
taken from his family). Nonetheless, his thyroidthan one week indicated an appropriate
function results confirmed the suspicion ofreplacement. His T4 levels showed
myxoedema coma, which explains the maskingimprovement, but remained low.
of expected hyperthermia due to septic shockAt that time, the patient became tachypnoeic and
(the patient showed a temperature of 36OC). Ondesaturated while on a non-rebreather mask at
that day, IV thyroxine was started at 200 mcg15 L, maintaining SpO2 at 91 % with a GCS
stat, and then reduced to 150 mcg daily.score of 15/15. CT chest revealed
The following day, the patient began tobronchiectasis. There was a rapid progression of
experience oro-nasal bleeding duringbronchiectasis cavitation on the right side with
suctioning, with secretions appearingnew consolidation in the basal left side, likely
moderately thick and bloody. Additionally,attributed to Pseudomonas or Staphylococcus
thrombocytopenia was observed, with a plateletinfection. Emphasis was placed on obtaining
count of 17x 10^3/μL, along with acute liversputum and secretion cultures with
failure indicated by elevated levels of aspartateantibiograms, IV colistin and IV imipenem for
aminotransferase (AST) at 4223 U/L andtreatment.
alanine aminotransferase (ALT) at 4248 U/L.15 days post-admission, the patient developed
To address these complications, the patientdrowsiness, hypotension, increased tachypnoea,
received nebulized tranexamic acid, along withand desaturation despite the non-rebreather
a transfusion of 4 units of fresh frozen plasmamask and BiPAP. His platelet count was 17 x
(FFP) and 6 units of platelets (PLT). Intravenous10^3/μL. Consequently, he was reintubated on
N-acetylcysteine was initiated at a dose ofthe same day and received a transfusion of 6
12000 mg over 1 hour, followed by 4000 mgunits of platelets. Although a bronchoscopy had
over 4 hours, and then 8000 mg over 16 hours.been planned, it was not performed due to the
Echocardiography revealed fair left ventricularpatient’s deteriorating condition.
systolic function with an ejection fraction (EF)25 days post-admission, the patient was in pre-
of 50 %. Cardiac dimensions were withinarrest status with refractory septic shock
normal limits, valves were normal, and the right(despite norepinephrine and vasopressin
side size and function were also normal. Noinfusion at high doses) and multi-organ failure.
masses or thrombi were observed and both theHe arrested at 4:48 AM; as the rhythm showed
The Journal of Medicine, Law & Public Health Vol4, No 2. 2024 p388
(PEA), cardiopulmonary resuscitation (CPR)hypotension, diagnostic and management
performed and return of spontaneous circulationmeasures should be implemented as soon as
(ROSC) was achieved after 12 minutes.possible for patients presenting with known
Venous blood gas post-ROSC showed pH 7.0,hypothyroidism, thyroidectomy, hypothermia,
pCO2 90 mmHg, HCO3 16 mmol/L, lactate 22and altered mental status, as mortality is high
mmol/L, and potassium 6.5 mmol/L.even with the best treatment [10].
Electrocardiogram (ECG) revealed no acuteAnnually, an estimated 7.9 million infants are
dynamic changes. Nonetheless, two hours later,born with a serious birth defect caused by
the patient arrested again. CPR was performedgenetic or largely genetic origin. The most
for 40 minutes with no response, and death wasfrequent severe aneuploid condition at birth is
declared.Down syndrome, which was initially reported in
II. DISCUSSION1866 by the British physician Dr. John Langdon
H. Down [11]. Despite their small and
We report a case of myxoedema coma caused byoverweight look, most children with Down
DKA and septic shock in a 42-year-oldsyndrome have normal thyroid function, while
individual with a medical history includingadults with Down syndrome tend to be more
Down syndrome, epilepsy, and type 1 diabetesprone to both hypothyroidism and
mellitus, who at the ED intubated for septichyperthyroidism. Hypothyroidism may be
shock caused by pneumonia and DKA. Thiscaused by the late development of thyroid
case is particularly unique in terms of theautoantibodies; testing thyroid-stimulating
clinical course. To the best of our knowledge,hormone (TSH) and blood thyroxine (T4)
there has been no mention in the literature oflevels, as well as triiodothyronine (T3) and T3
myxoedema coma triggered by DKA and septicresin uptake, can assist in diagnosing the
shock. Previous small case-series investigationscondition as well as weight loss, lethargy, heat
found the mortality rate for myxoedema coma tosensitivity, and skin abnormalities.
be 36% (4 out of 11 patients), 52% (12 out of 23In the present case, our patient had no history of
patients), and 25% (2 out of 8 patients) [9]. Duehypothyroidism, despite Down syndrome
to the condition’s rarity, the clinicalpatients having a high prevalence for thyroid
presentation, prognosis, and outcome werediseases such as thyroiditis and congenital
poorly Analysis Japan revealed recognized. of a nationwide that, out of 19 inpatient million database inpatients, inhypothyroidism pneumonia complicated [12,13]. He by septic was suffering shock; there from
149 were diagnosed with myxoedema coma,was no fever mentioned in the history prior to
with a mean age of 77 years and two-thirds ofhis arrival at the hospital, and his temperature
them women [9]. A retrospective multicentreduring hospitalization was 36-37OC. We believe
cohort study, by Simon Bourcier et al., ofthis was due to myxoedema and the absence of
critically ill severe hypothyroidism patients inthyroid hormone thermogenesis.
intensive care, found that the clinicalTypical presentation of patients with
presentation was hypothermia in 66% of cases,myxoedema may include hypothermia, dry skin,
hemodynamic failure in 57%, and coma in 52%.hoarseness, and altered mental status; however,
Furthermore, 54% were undiagnosed withthe absence of these symptoms does not rule out
hypothyroidism prior to ICU admission. Severethe diagnosis [14]. It is worth noting that sepsis
hypothyroidism can be triggered by theor DKA may be atypical manifestations of
termination of levothyroxine medication, sepsis,myxoedema, and the condition should thus be
or amiodarone-related hypothyroidism.considered in patients presenting with these
Although it is difficult to suspectsymptoms. In the present case, early recognition
hypothyroidism in the emergency departmentand treatment starting with supportive

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