A51-22 Silent Descent: Myxedema Coma Secondary to Levothyroxine Non Compliance

Abstract Introduction Myxedema coma is a critical endocrine emergency that represents extreme form of hypothyroidism. It is often triggered by factors like infection, surgery, or trauma and almost always occurs in the setting of untreated/inadequately managed hypothyroidism. Here, we highlight a successful management of myxedema coma due to non compliance with levothyroxine and co-existing bacteremia. Case Discussion 84 year old patient with a history of hypertension, hypothyroidism post thyroidectomy presented with complaints of progressive worsening generalized fatigue for 2 weeks. At presentation, he was hypothermic (temperature of 91.5 F) with pulse rate of 52 beats/min. Physical exam positive for lethargy and bilateral pitting pedal edema. Labs positive for sodium of 129 mmol/L. Other electrolytes were within normal limits. Complete blood count revealed: white blood cells count of 5,200/ul. Thyroid stimulating hormone was elevated at 81.90uIU/ml, free thyroxine was 0.1 ng/dl (0.3 - 1.4 ng/dl) and free triiodothyronine was 0.3 pg/ml (2.0 - 4.4 pg/ml). Cortisol level of 22.2 ug/dl (6.2- 19.4 ug/dl) and creatine kinase of 1571U/L (52 - 336 U/L). Blood and urine cultures were collected. MRI brain showed no acute intracranial pathologies and no pituitary lesion. Patient was started on warming therapy, intravenous levothyroxine, ceftriaxone and steroids. Patient’s clinical status remained unchanged after 48 hours of above treatment. Antibiotics was subsequently broadened to piperacillin/tazobactam after which patient’s clinical state began to improve. Blood cultures positive for Bacteriodes uniformis and antibiotics were narrowed to ampicillin/sulbactam. He was weaned off oxygen and discharged to rehabilitation facility with outpatient follow up. Discussion Hypothyroidism, particularly when associated with triggering factors, can lead to myxedema coma, a life- threatening condition characterized by clinical features such as altered mental status, hypotension, hypothermia, hyponatremia, bradycardia, and adrenal insufficiency. Interestingly, neither myxedema nor coma is necessary for diagnosis, as altered mental status and lethargy are frequently reported in clinical settings. Diagnostic evaluation using TSH and T4 levels is essential for confirming severe hypothyroidism. Conclusion Prompt medical intervention is crucial to reduce the risk of mortality associated with Myxedema coma. Initial management involves the administration of levothyroxine with initial high dose of IV 200-400 mcg then IV 50 - 100 mcg, then transitioned to oral 1.6 μg/kg body weigh. Evaluation for coexisting adrenal insufficiency is necessary, and may require intravenous glucocorticoids. Comprehensive supportive care for hypothermia, nutrition and monitoring for electrolyte abnormalities are essential aspects of management and addressing underlying triggering factors. Patient education on medication adherence is critical to preventing this complication. This abstract is funded by: N/A