A51-07 A Severe Case of Myxedema Coma Precipitated by Infection and Noncompliance

Abstract Myxedema coma is a rare and life threatening condition associated with hypothyroidism. Common precipitating factors include infection, burns, trauma, certain drugs, as well as many others. Myxedema coma presents with physical manifestations including hypotension, hypothermia, bradycardia, decreased mentation, hypoventilation, ileus, etc. Even with early diagnosis and treatment, the mortality rate is variable ranging between 20% to as high as 60%. Treatment involves intravenous levothyroxine loading dose of 200-400 µg followed by a daily dose of 1.6 µg/kg. Hydrocortisone 100mg IV every 8 hours is usually administered prior to thyroid hormone to address possible underlying adrenal insufficiency. Intravenous liothyronine is sometimes added if there is impaired T4-T3 conversion but high doses are not advised due to increased mortality risk. We present a case of a 58-year-old male with a past medical history of bipolar disorder, schizophrenia, hypertension, hypothyroidism arriving from a skilled nursing facility for altered mental status and hypoxia on 15L nasal cannula. Vital signs were notable for temperature 29.4 celsius, HR 46 bpm, RR 16, BP 82/59, Spo2 94%. Labs revealed a white blood cell count of 6.7, hemoglobin 10.8, platelets 89, creatinine 1.49, ALT 113, AST 165, ammonia 31, lactic acid 5.0, TSH 119.82 mcIU/mL, T4 0.4 ng/dl, Free T3 1.5, cortisol 19.9 µg/dl. Workup revealed a DVT of the right common femoral vein, femoral vein and popliteal vein, pulmonary embolism, ileus, and urinary infection with cultures growing Klebsiella pneumoniae group, carbapenem-resistant enterobacterales (CRE), multi-drug resistance (MDR). The patient was intubated for airway protection and given Atropine 1mg x2, 1 liter normal saline bolus, 100mg of hydrocortisone, 200 µg of levothyroxine, and initiated on norepinephrine 0.01-0.5 µg/kg/min. Endocrinology treated the patient for myxedema coma precipitated by a history of medication refusal and exacerbated by urinary tract infection and pulmonary embolism. IV levothyroxine was increased to 150 µg daily then to 190 µg daily. Liothyronine was initiated at 5 µg every 8 hours which was later decreased to 2.5 µg every 8 hours and stress dose steroids were added while on vasopressors. Vancomycin and cefepime were started which were later de-escalated to cefepime. The patient was weaned off vasopressors, steroids, and was ultimately extubated. Free t3, t4 normalized and the patient was transitioned to oral levothyroxine 250µg and Eliquis on discharge. This abstract is funded by: None