No body would dispute that myxoedema is the result of longstanding untreated hypothyroidism, but we still want to find an explnanation for the modest TSH elevation in such case.
regards
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
----- Original Message ----
From: Steve Angel <[log in to unmask]>
To: [log in to unmask]
Sent: Tuesday, 11 December, 2007 1:17:59 PM
Subject: Re: Incredibly myxoedematous
When last I checked, the degree of myxoedema was not correlated to the degree of hypothyroidism. If anything, it's related to the duration of untreated disease.
--- Dr. Steven Angel, MD, FRCPC General Pathologist Royal University Hospital Saskatoon, SK S7N 0W8
Date: Tue, 11 Dec 2007 04:01:52 -0800
From: [log in to unmask]
Subject: Re: Incredibly myxoedematous
To: [log in to unmask]
In other patients when FT4 is very low like 2.4 pmol/L, we often get a TSH of > 150 mU/L without any problem with hook effect, our method is Siemens advia XP. Moreover, the TSH now measures at 11.8 mU/L only 3-4 weeks after starting thyroxine, unlikely to have come down that quickly from > 150.
regards
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
----- Original Message ----
From: Mainwaring-Burton Richard (RGZ) <[log in to unmask]>
To: [log in to unmask]
Sent: Tuesday, 11 December, 2007 11:21:14 AM
Subject: Re: Incredibly myxoedematous
?? Hook effect on TSH assay ?
with best wishes
Richard
Richard Mainwaring-Burton
Consultant Biochemist
Queen Mary's Hospital
Sidcup, Kent
020-8308-3084
-----Original Message-----
From: Mohammad Al-Jubouri [mailto:[log in to unmask]]
Sent: 11 December 2007 11:07
To: [log in to unmask]
Subject: Incredibly myxoedematous
This is my contribution for the festive season, greetings to all list members.
It is rare to see myxoedema coma these days, but we had one admitted over this weekend. She is 67 year old, has been diagnosed 5 weeks ago with primary hypothyroidism (FT4 2.4 pmol/L and TSH 32.1 mU/L), was started on incremental dose of thyroxine 25, 50 then 75 mcg daily. The clinical details at the time were lymphoedema and joint pains. She decompensated metabolically probably due to UTI and presented with increasing confusion, hypothermia, shortness of breath and heavy legs. She looked grossly myxoedematous (you can list all textbook features), GCS 14/15, BP 94/70, Temp 35 C, RR 24/min, PR 60/min and blood tests showed severe hyponatraemia:
Sodium - 110
Potassium + 5.7
S.Osmolal - 227
Magnesium 0.78
Urea 4.9
Creatinine 65
eGFR >90
TropI <0.05
CRP + 44
Cortisol 549
FT4 - 7.0
TSH + 11.83
R. Glucose 5.5
Albumin 41
GGT 20
Adj.Calc. 2.18
ALT 30
Chol 4.40
ALP 109
CK + 897
Bilirubin 12
Albumin 41
Blood gases: pH 7.27, PCO2 10kPa, PO2 14.1kPa and HCO3 29 mmol/L.
Urinary sodium 32 mmol/L & osmolality 575 mOsmol/kg.
CXR showed bilateral pleural effusion, she was dmitted to HDU and commenced on i.v T3, 0.9% saline (then 1.8% saline) & HC therapy.
Two points for discussion:
First, the TSH of 32.1 mU/L at initial diagnosis is only modestly raised given how incredibly myxoedematous she is, any plausible explanation?
Second, Why not using intravenous T4 to reduce cardiovascular side effects?
regards
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
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