SUN-586 A Case Of Myxedema Coma With A Surprising Twist of SubAcute Infarct In The Frontal Lobe.

Abstract

Introduction: Myxedema Coma is a rare life threatening condition with a high mortality rate ranging from 25-60%. It results from longstanding, poorly controlled or undiagnosed hypothyroidism triggered by different precipitating factors including infections, cerebrovascular disease, myocardial infarction, and trauma or drug therapy. Hypothyroidism has a clear influence on atherosclerotic risk factors which may lead to cerebrovascular disease; however there is insufficient evidence to prove the relationship between these two distinct diseases. We present a case of myxedema coma with a surprising twist of sub-acute infarct in the frontal lobe. Case Presentation :61 year old female with history of diabetes mellitus and hypothyroidism due to non-adherence with thyroid hormone after total thyroidectomy for thyroid cancer presented with altered mental status. She was found after three days of no contact with her family, covered in her feces and urine. Physical exam showed hypothermia 86,3 o F, bradycardia 41 beats/min and puffiness of hands and face. Her laboratory showed elevated TSH 71.7 IU/ml, Free T4 0.22ng/dl, free T3 188pg/dl, high cortisol 33 UG/dl. EKG showed sinus bradycardia. Head CT noted for 1,6 by 1.5 hypodense lesions in frontal lobe concerning for sub-acute infarction. Myxedema coma was diagnosed with precipitating factor being stroke in the state of hypothyroidism and medication noncompliance and self-neglect due to frontal lobe sub-acute infarction. Admitted to ICU and started on intravenous Levothyroxyne , Liothyronine and cortisone. Due to worsening hypotension and respiratory status she was intubated and pressors -support was initiated. With clinical improvement on day three she was extubated and thyroid hormone replacement transitioned to oral regimen with good clinical outcome. Discussion : Myxedema refers to thickened, non-pitting edematous changes to the soft tissues of patients in a markedly hypothyroid state. With Hemodynamic instability, patient often progress into myxedema comatose state, which can be a life threatening condition if not treated quickly.Treatment involves intravenous administration of levothyroxine and Liothyronine supplements and often requires stress doses of steroids until adrenal insufficiency is excluded. We suspect that our patient developed self-neglect most likely due to her frontal lobe ischemia leading to further medication non-compliance which most likely precipitated the myxedema state given her thyroxin dependent state. Conclusion: Diagnosis of myxedema coma should always prompt inquiry into the possible precipitating factors and cerebrovascular accident especially with behavioral changes. Prompt recognition and supportive measures are extremely important in this endocrine emergency state.