A 73-year-old male presented with shortness of breath, cough, confusion and swelling throughout his body. His medical history included a pacemaker implantation and swelling below his eyes. Diagnostic tests found elevated cardiac and liver enzymes, low blood sugar and cortisol levels, and imaging showed pneumonia. He developed respiratory failure, heart issues, stroke and constipation over five days in the hospital. The patient was diagnosed with myxedema crisis, a life-threatening condition caused by severe hypothyroidism that affects multiple organ systems, which was likely precipitated by his pneumonia.

1. Myxedema Crisis
Travis Gerrard, MD

2. 73 year old male presents with SOB, cough,
confusion, anasarca

3. PMH
● Sick sinus syndrome who is status post
pacemaker placement 5 years ago
● Suborbital edema noted 3 months ago for
which he is planning to see a plastic surgeon
● Impaired fasting glucose

4. Diagnostics: Labs
● Troponin 0.16
● BNP 1341
● Glucose 62
● Elevated AST/ALT
● Random cortisol 13

5. Diagnostics: Imaging
● CT chest
● CT/CTA head
● Transthoracic Echocardiogram

6. Day 5
First stool of hospital stay

7. Patient Issues
● Hypoxic respiratory failure
● Pneumonia
● NSTEMI
● Acute CHF
● CVA
● Hypoglycemia
● Constipation

9. Cardiovascular
Bradycardia
Hypotension
Low cardiac output
Neuropsychiatric
Confusion
Lethargy
Coma
Respiratory
Hypoxia
Pleural effusions
Pneumonia (precipitating factor)
Renal / H2O metabolism
Hyponatremia
Anasarca
Bladder atony
Gastrointestinal
Constipation
Toxic megacolon
Metabolic
Hypothermia
Hypoglycemia
Clinical / lab features of myxedema crisis

12. Assumption bias
● Taking for granted that something has already
been done

13. Anchoring
● Focus on early signs/symptoms
● Tendency to regress toward the anchor
○ Ignore other information

14. Premature closure / Search satisfaction
● Accepting initial diagnosis
● Calling off search once reasonable
explanation found

15. Availability Heuristic
● Recent / more common diagnosis are easily
brought to mind

16. Take home points
- Hypothyroidism affects many organ systems
- Severe hypothyroidism mixed with an insult
can result in a myxedema crisis
- Be aware that biases exist
- Don’t know what we don’t know

17. 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.
● Kim, J. (2017). Myxedema — NEJM. New England Journal of Medicine. Retrieved 19 October 2017,
from http://www.nejm.org/doi/full/10.1056/NEJMicm1403210#t=article
● Pathology definition - Myxedema. (2017). Medical Zone. Retrieved 19 October 2017, from
http://www.medicalzone.net/pathology-definition---myxedema.html
● Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1
(2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.
● Icons: thenounproject.com, pvhc.com, shareicon.net, iconfinder.com, moziru.com,
commons.wikimedia.com, endlessicons.com

18. Questions?