Myxoedema coma is the most extreme manifestation of hypothyroidism. It is a state characterised by three major features:

  • Decreased level of consciousness
  • Defective thermoregulation
  • Cardiovascular collapse

This condition is well described in articles dating back to the 1950s.. Concerned about the lack of recent publications, new authors have stepped up to fill the void in the new century. From the exam perspective, it certainly seems to occupy a position of eminince in the minds of the examiners, perhaps out of proportion to its prevalence. Among the past papers, the following SAQs have explored myxoedema coma:

  • Question 13 from the second paper of 2018 (detailed exploration of management)
  • Question 30.1 from the first paper of 2014 (also some management)
  • Question 15.1 from the first paper of 2008 (recognise it from biochemical features)
  • Question 7 from the first paper of 2006 (recognise it from biochemical features)
Precipitating Causes of Myxoedema Coma

Drugs:

General anaesthetics

Lithium

Amiodarone

Barbiturates

Phenothiazines

Phenytoin

Rifampicin

Opiates

Weird causes

Consumption of raw bok choy

Illness

  • Surgery or trauma
  • Burns
  • Sepsis
  • Stroke
  • Congestive heart failure
  • GI bleeding
  • Hypoglycaemia
  • Acidosis
  • Hypoxia or hypercapnea

Most cases tend to present during cold weather, where the ambient temeprature lowers the threshold for encephalopathy. These cases tend to be elderly women, fond of self-negect, given to squalor in the autumn of their life.

Presentation of myxoedema coma

A great article form the American Family Physician goes through the various clinical features of myxoedema coma, which I have tabulated:

Clinical Manifestations of Myxoedema Coma

Cardinal features

Cardiovascular collapse, shock

Hypothermia

Decreased level of consciousness

Associated examination findings

A "puffy" face

Macroglossia

Periorbital oedema

Coarse, sparse hair

Non-pitting oedema

Goitre

Biochemistry

  • Hypothyroidism
  • Hypercapnea
  • Hypoxia
  • Hyponatremia
  • Hyposmolarity
  • Elevated protein levels on LP
  • High serum cholesterol

Other findings

Prolonged PR interval

Decreased QRS voltages, especially in the limb leads

Prolonged QT

Bradycardia

Pericardial effusion

Deep T-wave inversions

The ECG changes of myxoedema were recently trotted out into Question 12.2 from the first paper of 2018, where the presentation of the 73 year old female patient was in a state of dishevelment and with hypothermia. The CICM examiners used this LITFL ECG for the paper, which comes from the LITFL page on ECG changes associated with hypothyroidism. Specifically, they used "Example 2 - Myxoedema coma (after treatment)". Presumably they thought the deep T-wave changes in the pre-treatment example would distract the trainees and everybody would put "AMI" as one of their main differentials.

Myxoedema coma (after treatment)

Management of myxoedema coma

Management of this condition consists of the following steps:

  • Replace thyroid hormone - preferably IV
    • loading dose is 300-400μcg
    • a rising body temperature and normalising cardiovascular parameters alert you to the success of your management strategy
  • Replace corticosteroids - there is usually a concomitant adrenal insufficiency. One would use a "stress dose".
  • Correct the sodium: this is usually a hypervolemic hyponatremia which resembles that of CCF (in fact, it is because of exactly the same mechanism: poor cardiovascular performance leads to ADH and aldosterone driven retention of water and sodium, with a resulting hypervolemic hyponatremia. Because the patient is usually obtunded, one is obliged to correct a particularly low sodium with hypertonic saline, being careful not to demyelinate the CNS.
  • Good solid supportive management:  this seemed necessary in the CICM answer to Question 13 from the second paper of 2018, even though it is in no way specific to the management of myxoedema coma.
    • Establish an airway if this is needed
    • Maintain normoxia and normocapnea with the ventilator
    • Maintain normotension to support organ system perfusion, with a catecholamine infusion
    • Correct the Na+ deficit - consider using water restriction alone.
    • Correct hypoglycaemia
    • Correct hypothermia with warming blanket

References

Summers, V. K. "Myxoedema coma." British medical journal 2.4832 (1953): 366.

Wartofsky, Leonard. "Myxedema coma." Endocrinology and metabolism clinics of North America 35.4 (2006): 687-698.

Mathew, Vivek, et al. "Myxedema coma: a new look into an old crisis." Journal of thyroid research 2011 (2011).

Lezama, Maybelline V., Nnenna E. Oluigbo, and Jason R. Ouellette. "Myxedema Coma and Thyroid Storm: Diagnosis and Management." Internal Medicine 14.Part 2 (2011): 1.

Chu, Michael, and Terry F. Seltzer. "Myxedema coma induced by ingestion of raw bok choy." New England Journal of Medicine 362.20 (2010): 1945-1946.

Wall, Cristen Rhodes. "Myxedema coma: diagnosis and treatment." American family physician 62.11 (2000).

Bondugulapati, Laxmi, Mohamed Adlan, and Lakdasa Premawardhana. "Thyroid Emergencies." Sri Lanka Journal of Critical Care 2.1 (2011): 1-12.