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
__________________________________________________________
Sent from Yahoo! Mail - a smarter inbox http://uk.mail.yahoo.com
------ACB discussion List Information--------
This is an open discussion list for the academic and clinical
community working in clinical biochemistry.
Please note, archived messages are public and can be viewed
via the internet. Views expressed are those of the individual and
they are responsible for all message content.
ACB Web Site
http://www.acb.org.uk
List Archives
http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
List Instructions (How to leave etc.)
http://www.jiscmail.ac.uk/
