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Patient: Male, 71-year-old Final Diagnosis: Myxedema coma Symptoms: Altered mental state • bradycardia Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic Objective: Rare disease Background: Myxedema coma is an uncommon severe thyroid disorder that is fatal in 25–60% of cases. Although the differential diagnosis for altered mental status is extensive, including many more common causes such as infection, medication changes, electrolyte abnormalities, and exacerbation of chronic illnesses, profound hypothyroidism is an uncommon cause that can be overlooked. Case Report: We describe the case of a 71-year-old man on long-term amiodarone treatment for atrial fibrillation who presented with altered mental status initially ascribed to uremia, hyponatremia, and pneumonia. When his mental status did not resolve, thyroid tests showed his thyroid-stimulating hormone level was 89 μIU/mL, along with clinical criteria for myxedema coma. Conclusions: We suggest that thyroid function tests should be considered in encephalopathic older adults on amiodarone.

We report a case of an elderly Caucasian male with past medical history of dextrocardia with situs inversus totalis, polymyalgia rheumatica, history of cryptogenic stroke, and severe mitral regurgitation with mitral valve prolapse, who presented with acute heart failure symptoms, including severe dyspnea on exertion and worsening lower extremity edema in the setting of immunosuppression with steroids for a year-old diagnosis of polymyalgia rheumatica. One month prior to this presentation, the patient suffered a transient ischemic attack and during the workup, his transthoracic echocardiography showed myxomatous degeneration of posterior mitral leaflet, partially flail, with severe mitral regurgitation, which required mitral valve replacement. Genome sequencing of mitral valve anterior leaflet pathology detected Tropheryma whipplei as a causal agent of culture-negative endocarditis. The patient was treated with 6 weeks of ceftriaxone and ampicillin–sulbactam and further continued trimethoprim–sulfamethoxazole for 1 year. He continued antibiotic treatment with resolution of shortness of breath along with arthralgia.

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