A Diagnostic Scoring System for Myxedema Coma

Popoveniuc, Geanina; Chandra, Tanu; Sud, Anchal; Sharma, Madhu; Blackman, Marc R.; Burman, Kenneth D.; Mete, Mihiriye; Desale, Sameer; Wartofsky, Léonard

doi:10.4158/ep13460.or

Cited by 81 publications

(80 citation statements)

References 22 publications

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“…In our patient, the myxedema coma diagnostic score was 110 with N65 being highly suggestive of myxedema coma [9]. Myxedema coma typically occurs after an inciting event such as infection, trauma, MI, CVA, CHF, or medication non-adherence which was not present in our patient.…”

Section: Contents Lists Available At Sciencedirectmentioning

confidence: 54%

“…Myxedema coma typically occurs after an inciting event such as infection, trauma, MI, CVA, CHF, or medication non-adherence which was not present in our patient. It is most commonly associated with primary hypothyroidism and rarely associated with central or secondary hypothyroidism (4/23 and 0/21 in two case series) [9,10]. The association of myxedema coma with a cerebral artery aneurysm has not been previously described to our knowledge.…”

Section: Contents Lists Available At Sciencedirectmentioning

confidence: 87%

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Carotid artery aneurysm resulting in myxedema coma

Lamos

Woodworth

Munir

2015

Interdisciplinary Neurosurgery

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Intra-sellar aneurysms are a rare, but important consideration when evaluating pituitary masses. Identification of aneurysms is critical to appropriate treatment and avoiding perilous consequences. These vascular aneurysms can result in severe endocrine dysfunction due to mass effect, stripping of the vascular supply to the pituitary, or hemorrhage. Here we describe a novel case of spontaneous myxedema coma and pituitary apoplexy secondary to a large internal carotid artery aneurysm. IntroductionAneurysms with components extending into the sella turcica a rare, but important consideration when evaluating sellar and parasellar masses. Mistaking a calcified and/or partially thrombosed aneurysm for a tumor can have catastrophic intra-operative consequences. Severe endocrine dysfunction is uncommon, but may result from mass effect, vascular steal phenomenon, or hemorrhage. Here we describe a rare case of spontaneous myxedema coma and pituitary apoplexy secondary to a large internal carotid artery aneurysm. Case reportA 78-year-old woman presented with symptoms of sudden polyuria, headache, and vomiting for 24 h. Bradycardia (52 bpm), hypothermia (33.9°C) and hyponatremia (sodium 117 mmol/L) were present on initial assessment. She reported a history of a sellar mass initially diagnosed 24 years earlier. She had refused surgery and opted to monitor the lesion with serial imaging. Per the family and patient, her hormonal blood work was normal and the mass had been stable, not requiring treatment. She had a stable left homonymous hemianopsia for many years. A large mixed density sellar mass was confirmed on initial CT imaging and she was referred for urgent neurosurgical evaluation. Prior to evaluation, she became disoriented and hypotensive requiring hemodynamic support and intubation for airway protection. Exam was notable for Glascow coma scale of 9/15 (E3, V1, M5), minimal reactive pupils bilaterally, and delayed tendon reflexes at the biceps; no significant cranial nerve, motor or sensory deficits were identified. Formal visual fields were not testable. Her skin and mucosa were normal with minimal peripheral edema. She was empirically treated for myxedema coma and adrenal crisis due to presumed pituitary apoplexy. Intravenous levothyroxine (T4), liothyronine (T3), and hydrocortisone were initiated. Central hypothyroidism and central adrenal insufficiency were later confirmed with a low free thyroxine (0.4 ng/dL), low total T3 (76 ng/dL), low cortisol (0.7 μg/dL), inappropriately normal TSH (3.57 mIU/L) and normal ACTH (16.5 pg/mL), respectively. Prolactin was mildly elevated (56.2 ng/mL). MRI (Fig. 1) revealed a 5 × 3.2 cm heterogeneous mass centered in the sella turcica extending into the left cavernous sinus with lack of flow void in the petrous and distal cavernous portions of the left internal carotid artery. The optic chiasm was poorly visualized due to significant displacement by the mass. The differential diagnosis included hemorrhage within a pituitary macroadenoma, other tumors including osteosarcoma, osteo...

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Section: Contents Lists Available At Sciencedirectmentioning

confidence: 54%

Section: Contents Lists Available At Sciencedirectmentioning

confidence: 87%

Carotid artery aneurysm resulting in myxedema coma

Lamos

Woodworth

Munir

2015

Interdisciplinary Neurosurgery

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“…Another finding in MC can be a prolonged QT segment [9], which this patient exhibited prior to treatment. Two different groups have proposed clinical scoring criteria for diagnosing MC [10, 11], and this patient would have been diagnosed and recommended for treatment by both systems.…”

Section: Discussionmentioning

confidence: 99%

Myxedema Coma due to Hashimoto Thyroiditis: A Rare but Real Presentation of Failure to Thrive in Infancy

Heksch¹,

Henry²

2018

Horm Res Paediatr

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Background: Hashimoto thyroiditis (HT) is uncommon in infancy, and myxedema coma (MC) is even less common. While prior reports have documented these entities separately, to our knowledge, MC in combination with HT has not been reported before in this age group. Methods/Results: A 10-month-old female presented with ptosis, lethargy, dysphagia, and failure to thrive (FTT). She developed hypotension, bradycardia, hypothermia, and apnea requiring intubation. Initial thyroid-stimulating hormone was 422 μIU/mL, and free thyroxine was < 0.5 ng/dL, despite the presence of a normal thyroid newborn screen (NBS). Of note, sepsis workup was unremarkable. With the diagnosis of MC, treatment with intravenous levothyroxine was initiated, although after hydrocortisone administration to avert the possibility of an adrenal crisis, despite a random cortisol of 16.4 μg/dL. Based on positive thyroid antibodies suggesting HT, autoimmune workup later revealed positive acetylcholinesterase antibodies consistent with a diagnosis of ocular myasthenia gravis. Conclusion: MC may be a cause of altered mental status in infancy and may simultaneously be associated with FTT on presentation. With the presence of a normal thyroid NBS, autoimmunity should be entertained as the etiology of profound hypothyroidism, as positive thyroid antibodies may prompt an exploration for coexisting diseases which may explain other presenting features.

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“…Since the time our preliminary findings and initial myxedema coma screening tool were introduced in 2011 (8), we have become aware of a recently published manuscript with a scoring system for myxedema coma that is similar but more comprehensive than our own (23). The more involved system includes gastrointestinal findings, a list of cardiovascular problems (in addition to bradycardia), and several conditions of metabolic disturbance.…”

Section: Discussionmentioning

confidence: 99%

Development of an objective tool for the diagnosis of myxedema coma

Chiong

Bammerlin

Mariash

2015

Translational Research

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Myxedema coma, a rare entity with a reported 25-65% mortality had no objective criteria for making the diagnosis when we began our study. We developed an objective screening tool for myxedema coma to more easily identify patients and examine the best treatment method in future prospective studies to reduce the mortality of this entity. We conducted a retrospective chart review to find all patients aged ≥ 18 years admitted with myxedema coma from 1/1/2005 through 6/13/2010 at Indiana University Health Methodist Hospital. Based both on our retrospective chart review and on literature-based accounts, we identified 6 criteria to diagnose myxedema coma. We identified 10 patients initially diagnosed with myxedema coma and established a control group consisting of 13 patients identified with altered mental status and elevated TSH levels. The six variables we created for the screening tool are heart rate, temperature, Glasgow coma scale, thyroid stimulating hormone, free T4, and precipitating factors. The screening tool has a sensitivity and specificity of about 80%. We ran a logistic regression model using the 10 study patients and 13 controls with the 6 variables. No variables alone significantly contributed to the model. However, the overall model was highly significant (P = 0.012), providing strong support for a scoring system that uses these variables simultaneously. This screening tool enables physicians to rapidly diagnose myxedema coma to expedite treatment. A more refined diagnostic tool may be used in future clinical studies designed to determine the optimal treatment.

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A Diagnostic Scoring System for Myxedema Coma

Cited by 81 publications

References 22 publications

Carotid artery aneurysm resulting in myxedema coma

Carotid artery aneurysm resulting in myxedema coma

Myxedema Coma due to Hashimoto Thyroiditis: A Rare but Real Presentation of Failure to Thrive in Infancy

Development of an objective tool for the diagnosis of myxedema coma

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