Case Presentation• 47 yo CM presented to office with Complain of falls, leg edema and pain, fatigue, drowsiness, headaches, shortness of breath, drowling from angle of mouth, and weight gain.• Headache mostly on left, for 2 yrs since he was it in the head with a gun during mugging.• Falls, mostly on rt side, resurrent, no loss of concoiusness, no jerky movements, no trauma• Leg swelling & pain, started 3 yrs ago, gradual, worst when standing for a long time, worst with drinking soda.• Cannot sleep in bed and sleeps in chair.
Case PresentationReview of SystemsGeneral : sweats, anorexia, fatigue, weakness, malaise, and sleep disorder.Eyes : blurring, halos, discharge, and light sensitivity.ENT nosebleeds.CV difficulty breathing at night, near fainting, chest pain or discomfort, racing/skipping heart beats, fatigue, lightheadedness, shortness of breath with exertion, palpitations, swelling of hands or feet, difficulty breathing while lying down, and leg cramps with exertion.Resp sleep disturbances due to breathing, shortness of breath, chest discomfort, and excessive snoring.GI loss of appetite, gas, abdominal bloating, and change in bowel habits.GU urinary frequency and nocturia.MS muscle cramps, joint pain, joint swelling, back pain, stiffness, muscle weakness, arthritis, loss of strength, and muscle achesDerm excessive perspiration, night sweats, dryness, changes in color of skin, flushing, and rash.Neuro poor balance, headaches, disturbances in coordination, numbness, inability to speak, falling down, tingling, brief paralysis, visual disturbances, weakness, and excessive daytime sleeping.Psych anxiety, depression, thoughts of violence, and frightening visions or sounds.Endo cold intolerance, heat intolerance, and weight change.Heme skin discoloration .
Case PresentationPMH:HypertensionThyroid Disorder-Hypothyroidism 1998Night terrorsSinusitisMedications• LASIX 40 MG TAB 1 Tab by mouth daily• SYNTHROID 0.15 MG TAB 1 Tab by mouth dailyPt ran out of it few months ago.• ADVIL 500 MG
Case Presentation Social History:Past Surgical History: Patient currently not sexually active Thyroidectomy 2/98 Uses condoms when active Shoulder 1/2004 No H/O STDs Hospitalization at winchester due to MVA has never been tested for HIV H/o Sexual abuse/Physical abuse/Verbal AbuseFamily History: Lives at a house with roommates FH Diabetes Unemployed FH Heart Disease, Mother, Sister is a college Graduate Family History of Angina FH Hypertension FH Stroke FH Cancer Father, Mother FH Alzheimers, Mother FH Suicide, Sister
ExaminationGeneral: • BMI:49.20, O2 Sat: 94 % well developed, well nourished, in acute • Pulse rate:70 / minutedistress. obese, poor hygeine, and unkempt.Head: • BP: 148 / 90 normocephalic and atraumatic. Msk:Eyes: unsteady gait. PERRL/EOM intact, conjunctiva and sclera Pulses:clear with out nystagmus. UE 2+Ears: LE Not palpable canals clear, tympanic membranes intact, Extremities:no fluid. 4+ edema pitting/nonpitting BL Lower ExtNose: upto knees, 4+ edematous/Swollen feet no deformity, discharge, inflammation, orlesions. Cervical Nodes:Mouth: no significant adenopathy. Drooling from right angle of mouth Psych:Neck: depressed affect, anxious, and easily supple, no masses, tenderness or distracted.enlargement. enlarged thyroid. episodes of crying during the interview
ExaminationLungs: clear bilaterally to auscultation. nointercostal retractions or use of accessorymuscles. no rales, rhonchi or wheezes.accessory muscle usage.Heart: regular rate and rhythm, S1, S2 withoutmurmurs, rubs, or gallops.Abdomen: soft,non-distended, positive bowel sounds,no tenderness.Neurologic: no focal deficits, cranial nerves II-XII grosslymuscle strength . Slurred Speech, Reflexes notappreciable.
Labs & ImagingSODIUM 139 MMOL/L 135-146 POTASSIUM 4.4 MMOL/L 3.5-5.1 CHLORIDE 98 MMOL/L 96-106 CO2 [H] 33 MMOL/L 24-32! ANION GAP 8 MMOL/L 5-16 GLUCOSE 70 MG/DL 70-110 BUN [H] 25 MG/DL 10-20 CREATININE 1.3 MG/DL 0.7-1.3 CALCIUM 9.1 MG/DL 8.5-10.5 AST 29 U/L 15-37 ALT 31 U/L 25-65 ALK PHOS 78 U/L 50-136 TOT PROTEIN 7.8 G/DL 6.5-8.0 ALBUMIN 4.9 G/DL 3.4-5.0 BILI,TOTAL 0.4 MG/DL 0.0-1.0
Labs & ImagingCT Scan:There is no evidence for acute intracranial hemorrhage or mass effect.Stable appearance of the ventricles and sulci when compared to prior study dated 3 December 2008.
Labs & ImagingCT Scan:There is no evidence for acute intracranial hemorrhage or mass effect.Stable appearance of the ventricles and sulci when compared to prior study dated 3 December 2008.CXRNo acute pulmonary process.
Labs & ImagingCT Scan:There is no evidence for acute intracranial hemorrhage or mass effect.Stable appearance of the ventricles and sulci when compared to prior study dated 3 December 2008.CXRNo acute pulmonary process.EchoLimited but ProbablyNormal Study
Labs & ImagingCT Scan:There is no evidence for acute intracranial hemorrhage or mass effect.Stable appearance of the ventricles and sulci when compared to prior study dated 3 December 2008.CXRNo acute pulmonary process. TSHEcho 56.800 uIU/mLLimited but Probably 0.350-5.50Normal Study T3, Total <40 NG/DL 60-181
Myxedema Coma: Decompansated Hypothyroidsm Myxedema coma is a loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood (hypothyroidism). It is considered a life-threatening complication of hypothyroidism and represents the far more serious side of the spectrum of thyroid disease.• Very high mortality 1:3• Undiagnosed Hypothyroidism or usually Untreated. Often linked to a precipitant, such as acute infection, myocardial infarction, congestive heart failure, cerebral vascular accident, trauma, or drug toxicity• Typical patient: elderly female with longstanding hypothyroidism,• Previous thyroid surgery, History of hypothyroidism, Levothyroxine replacement, thyroid cancer, surgery, RAI
Myxedema Coma: Decompansated Hypothyroidsm• Mortality rate in myxedema coma has historically been as high as 80%• disease appears more often in white and Hispanic populations• greater in females than males (female-to-male ratio 5-10:1• The incidence of primary hypothyroidism increases progressively with age, typically at 40- 50 years. After age 60 years, the prevalence of hypothyroidism may be as high as 8-10% in women.
History and Symptoms• Typical Stigmata: dry skin, delayed reflex relaxation, generalized weakness, edema. Alterations- mental status.• Lethargy• Brittle or thinning hair, Dry Hair• Menstrual irregularity• Menorrhagia• Forgetfulness• Deep, husky voice secondary to mucopolysaccharide infiltration of the vocal cords• Cold intolerance• Weight gain• Muscle/joint pain or weakness• Inability to concentrate• Headaches• Constipation• Emotional lability• Depression• Blurred vision
Causes Of HypothyroidsmWorldwide : Iodine DeficiencyUsa : Hashimoto Thyroiditis & Iatrogenic Secondary to treatment of Graves Disease i.e. surgical or radioactive iodine ablation of the thyroid gland
Causes Of Hypothyroidsm Worldwide : Iodine Deficiency Usa : Hashimoto Thyroiditis & Iatrogenic Secondary to treatment of Graves Disease i.e. surgical or radioactive iodine ablation of the thyroid glandPrimary causes : 90-95 % autoimmune, idiopathic, postoperative, andcongenital etiologies; radiation; radioiodinetherapy; iodine deficiency; metabolicdisorders; and medications (eg, lithium,amiodarone, phenytoin, carbamazepine,iodides). Furthermore, those with underlyingautoimmune thyroiditis are susceptible todisease progression while taking thesemedications.
Causes Of Hypothyroidsm Worldwide : Iodine Deficiency Usa : Hashimoto Thyroiditis & Iatrogenic Secondary to treatment of Graves Disease i.e. surgical or radioactive iodine ablation of the thyroid glandPrimary causes : 90-95 % autoimmune, idiopathic, postoperative,and congenital etiologies; radiation;radioiodine therapy; iodine deficiency;metabolic disorders; and medications(lithium, amiodarone, phenytoin,carbamazepine, iodides). Secondary causes pituitary and hypothalamic disorders such as trauma, neoplasm, irradiation, and infiltrative diseases including sarcoidosis or amyloidosis
Workup• Basic lab tests and radiology• FT4, TSH• CBC (anemia), electrolytes (hyponatremic),Hypoglycemia• renal function (increased Cr)• EKG (bradycardia), CXR (effusions)• Evaluate for pituitary disorders & Coexisting autoimmune disorders• Cortisol, cosyntropin stimulation test• FSH, LH• ABG: Hypoventilation commonly results in hypercapnia and hypoxia in patients with myxedema coma• Blood / Urinary Cultures
Thyroid Studies• Thyroid function studies may not be immediately available to assist in clinical decision making in the ED.• Thyroid-stimulating hormone (TSH) is elevated in primary hypothyroidism, but it may be normal or low in secondary causes of hypothyroidism.• Free thyroxine (T4) levels are low.• Triiodothyronine (T3) resin uptake is decreased.• Free T4 index (T3 resin uptake x total serum T4) is low.• Critically ill patients may develop euthyroid sick syndrome, which must not be confused with a primary thyroid abnormality. These patients have low to normal TSH and T4 levels with low T3 levels.
Imaging• Head CT scan (noncontrast) In patients with altered mental status, the scan may be helpful in ruling out other etiologies such as intracerebral hemorrhage.• Echocardiography: Perform this study if pericardial effusion is suspected• Chest radiography : Cardiomegaly, Effusions
Treatment• ICU admission may be required for ventilatory support and IV medications• Parenteral thyroxine – Loading dose of 300 – 400 μg – Then 50 μg daily• Electrolytes – Water restriction for hyponatremia – Avoid fluid overload• Avoid sedation• Hypothermia, Regular Blankets• Glucocorticoids – Controversial but necessary in hypopituitarism or multiple endocrine failure – Dose: Hydrocortisone 40 – 100 mg 6 hly for 1 week, then taper
Treatment• Typical levothyroxine dose estimate 1.6 mcg/kg/day• iv levothyroxine is about 2X more potent than• oral levothyroxine once stable• T3 usually not needed• Endocrinologist Should be Consulted.• Mortality lowered From 70% to 15-30%.
Pearls• Medication metabolism can be affected• Hypothyroidism induced ileus causing poor absorption• Decreased metabolism and clearance (eg sedatives, opiates)• Replacement of thyroid hormone can precipitate angina or MI in at-risk patients• Thyroid hormone treatment may unmask underlying adrenal insufficiency• Consider pregnancy test if reproductive age• May affect anticoagulation – must monitor• Be careful of euthyroid sick syndrome• Young, active patients can tolerate sever hypothyroid symptoms for a long time• Myxedema can be seen in both hyper and hypothyroidism