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Myexedema crisis

Presented this poster at the ACP Washington Chapter Scientific Meeting November 2– 4, 2017

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Myexedema crisis

  1. 1. Myxedema crisis An uncommon effect of a common condition Travis Gerrard, MD, PGY3 at Virginia Mason Medical Center ▪ Hypothyroidism is a common condition effecting 10% of population ▪ Myxedema crisis is a much less common but serious sequela of untreated hypothyroidism Introduction Case Learning points ▪ Features of hypothyroidism were present in patient prior to hospitalization (SSS, suborbital edema), yet surprisingly a TSH was not checked until hospital day 8. This was the result of several biases. ▪ Anchoring bias: ▪ PNA as initial diagnosis ▪ Likely a true diagnosis, but also the precipitant of his myxedema crisis ▪ As symptoms evolved, anchored onto common dx in elderly with premature closure bias ▪ CHF due to ischemia but deferred cardiac cath given his acute PNA ▪ CVA with inability to get MRI due to pacemaker ▪ Availability bias was also present ▪ The above diagnoses are common in elderly hospitalized patients ▪ Myxedema crisis is an uncommon diagnosis. Patient presented without coma or need for intubation, possibly due to PM supporting patients cardiac output ▪ Have a low index of suspicion in elderly to check TSH ▪ Never assume: In this instance that a TSH had been checked. Cardiovascular Bradycardia, Hypotension Respiratory Hypoxia Gastrointestinal Constipation Neuropsychiatric Confusion, Lethargy, Poor cognitive function Renal and water metabolism Anasarca, Hyponatremia Metabolic Hypoglycemia Features of myxedema crisis in patient References • Mathew, Vivek et al. “Myxedema Coma: A New Look into an Old Crisis.” Journal of Thyroid Research 2011 (2011): 493462. PMC. Web. 9 Oct. 2017. • Popoveniuc, G., Chandra, T., Sud, A., Sharma, M., Blackman, M. R., Burman, K. D., ... Wartofsky, L. (2014). A diagnostic scoring system for myxedema coma. Endocrine Practice, 20(8), 808-817. DOI: 10.4158/EP13460.OR • Kim, J. (2017). Myxedema — NEJM. New England Journal of Medicine. Retrieved 19 October 2017, from • Bahn, R. (2017). Graves' Ophthalmopathy — NEJM. New England Journal of Medicine. Retrieved 19 October 2017, from • Pathology definition - Myxedema. (2017). Medical Zone. Retrieved 19 October 2017, from ▪ 77 y/o male who 5 years ago developed sick sinus syndrome (SSS) and underwent pacemaker (PM) implantation ▪ 3 months ago noted to have suborbital edema ▪ Presented in the night with confusion, SOB, purulent cough, anasarca ▪ Started on abx given finding of infiltrate on chest CT ▪ Hospital day (HD) 2 patient developed dysarthria, hypotension, hypoxemia & hypoglycemia. ▪ Work up for stroke, Addison's, ACS only remarkable ECHO showing left ventricular ejection fraction of <40%, global hypokinesis. Unable to get head MRI due to PM ▪ HD 5, senior residents switch, patient has first bowel movement of hospital stay ▪ HD 7, interns off. Pt with persistent hypotension & hypoglycemia. Surprise when discovered patient never had TSH checked ▪ HD 8, on AM labs patient found to be profoundly hypothyroid, IV replacement with levothyroxine is initiated ▪ HD 9, patient with rapid improvement of confusion, hypoxia, hypotension & hypoglycemia Examples of suborbital edema