The typical patient presenting with myxoedema coma is a woman in the later decades of her life who may have a history of thyroid disease and who is admitted to hospital during the winter months, possibly with pneumonitis. Physical findings could include brady cardia, macroglossia, hoarseness, delayed reflexes, dry skin, general cachexia, hypotension, hypoventilation, and hypothermia, commonly without shivering. Even though specific diagnostic criteria are not available a diagnostic scoring system has been proposed. Based upon the presence of thermoregulatory and central nervous system dysfunction, gastrointestinal findings, precipitating events, cardiovascular dysfunction, and metabolic alterations, the scoring system has reached a sensitivity of 100% and specificity of 80% (Table 1). According to the score achieved, the patient would be classified as either highly suggestive, suggestive, or un likely to have myxoedema coma. Another objective screening tool was proposed based on heart rate, temperature, Glasgow coma scale, TSH, free thyroxine, and precipitating events which was associated with a sensitivity and specificity of approximately 80%. Despite the importance that both scoring systems could have in allowing early diagnosis and initiation of treatment, the limited number of patients in these studies requires additional validation.

Table1. Diagnostic scoring system for myxoedema coma

Laboratory evaluation may indicate anaemia, hyponatraemia, hypercholesterolaemia, and increased serum lactate dehydrogenase and creatine kinase. On lumbar puncture there is increased pressure and the cerebrospinal fluid will have a high protein content. The electrocardiogram and chest radiograph may demonstrate the characteristic findings described earlier. If hypothyroidism is suspected in a comatose patient, blood should be obtained for thyroid function testing, but treatment should not be delayed awaiting laboratory confirmation of the diagnosis. On the other hand, a correct diagnosis is particularly important because the unnecessary administration of large doses of T4 or T3 to an elderly euthyroid patient could induce a fatal arrhythmia or coronary event. In addition to routine thyroid function tests, ancillary studies should be performed to determine whether CO2 retention, hypoxia, hyponatraemia, or infection are present. Indeed, in many patients the clinical features may be so notable as to render the measurement of thyroid function tests necessary only for confirmation of the diagnosis. The urgency of the diagnosis should be stressed to the laboratory, which often can perform a serum T4 and TSH determination in 3– 4 h. Although an elevated serum TSH concentration is the most important laboratory evidence of the diagnosis, the presence of severe complicating systemic illness or treatment with drugs such as dopamine, dobutamine, or corticosteroids may serve to reduce the elevation in TSH levels. Furthermore, an association between the use of catecholamines and higher mortality has been reported. There may also be a pituitary cause for the hypothyroidism, in which case an increased TSH would not be found. Until the presence of pituitary disease is ruled out, corticosteroid therapy is recommended in addition to T4.

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مواضيع ذات صلة

Myxoedema Coma: Thyroid Hormone Therapy

Myxoedema Coma: Hyponatraemia

Pathophysiology of Unstable Hemoglobin Disorders

Central Hypothyroidism

Severe Iodine Deficiency and natural Goitrogens

Iatrogenic Hypothyroidism

Pathobiology of Sickle Cell Disease: The Basis of Phenotypic Diversity

The Unique Systems Biology of Sickle Cell Anemia

Abnormalities of Sickle Red Blood Cells

Abnormal Molecular Behaviors of Sickle Hemoglobin

Clinical Assessment and Systemic Manifestations of Hypothyroidism: Diagnostic Accuracy

Clinical Aspects of Hypothyroidism due to Different Aetiologies