Abstract Introduction Myxedema coma is a rare, life-threatening manifestation of severe hypothyroidism that often mimics acute neurologic emergencies, causing diagnostic delays. Despite prompt treatment, mortality remains high at 25-50%, with an increasing trend documented over recent years. Atypical presentations, especially those mimicking stroke, pose significant diagnostic and management challenges. Case Description A 79-year-old woman with coronary artery disease, atrial fibrillation, chronic kidney disease, hypertension, and hypothyroidism presented with sudden dysarthria and confusion, leading to urgent stroke protocol activation. During CT imaging, she developed agonal respirations and suffered two cardiopulmonary arrests, with a total downtime of 11 minutes, ultimately achieving ROSC. Her ECG showed junctional bradycardia (40-50 bpm) and a QTc interval of 610 ms, indicating significant arrhythmogenic risk. Laboratory tests revealed a markedly elevated TSH (133 µIU/mL) with low free T4, confirming myxedema coma. Imaging excluded stroke, pulmonary embolism, dissection. She received IV levothyroxine, hydrocortisone, ventilatory support, and dobutamine. Over days, her mental status and cardiac function recovered, with ejection fraction normalizing from 33%. She was discharged on stable oral thyroid therapy. Discussion Myxedema coma typically develops gradually, but this patient presented suddenly with confusion and slurred speech, appropriately triggering stroke protocol. Yet this focus delayed recognition of the actual diagnosis, a well-documented problem. Literature emphasizes that myxedema coma is "often missed or delayed due to various clinical findings," and specifically highlights that "myxedema coma masquerading as acute stroke" remains a common diagnostic trap. The cardiac involvement was striking and rare. Torsades de pointes occurs in approximately 6 to 7 percent of severe hypothyroidism cases. This patient's TSH of 133 with a QTc of 610 milliseconds created exceptional arrhythmogenic risk, resulting in cardiac arrest, an event that increases mortality nearly ninefold. Despite the expected poor prognosis, her heart function recovered completely with thyroid hormone replacement alone. Published cases emphasize that "missing myxedema coma diagnosis is a major cause of increased mortality," and highlight that "high clinical suspicion enables timely diagnosis and appropriate treatment." The Pasquali diagnostic scoring system (score ≥60: 100% sensitivity) offers a practical solution. When patients present with sudden confusion and bradycardia, incorporating this validated tool alongside stroke evaluation could identify myxedema coma before hemodynamic collapse. For this patient, systematic recognition might have prevented cardiac arrest entirely. This abstract is funded by: None
Boodhun et al. (Fri,) studied this question.