SUN-584 Unusual Presentation Of Myxedema Coma

Introduction Myxoedema coma is an uncommon, life-threatening form of longstanding, neglected, untreated hypothyroidism.It is precipitated by an acute illness such as infections, myocardial infarction, cold exposure, or use of sedative drugs. It is characterized by lethargy, myxedematous manifestations and altered sensorium. We are presenting a case of myxedema associated with large unilateral pleural effusion and tachycardia. Case Presentation A 74 years old female with history hypothyroidism not in thyroid replacement for the past two years presented with urinary incontinence, progressive dyspnea, generalized weakness, confusion, anorexia, and constipation for the past two months. She was found to be somnolent, hypothermic, hypoxic, tachycardic with mild enlargement of thyroid gland, pretibial edema and delayed deep reflexes response. Chest x-ray showed a large right sided pleural effusion. Labs revealed macrocytic anemia, leukopenia, thrombocytopenia, TSH 214 micro IU/ml, free T4 0.14 ng/dl and free T3 less than 50 pg/dl. Urinalysis showed pyuria. Pleural fluid revealed transudate.Initially she was treated with ceftriaxone for UTI and intravenous Levothyroxine, Liothyronine, hydrocortisone for the myxedema. Despite initiation of treatment worsening hypoxemia and hypercapnia led to noninvasive ventilation and further intubation . She was extubated and continued on oral thyroid replacement therapy. Discussion Myxoedema coma has an incidence rate of 0.22 per million per year. The syndrome is more commonly seen in elderly women with longstanding hypothyroidism.Serious effusions, including pleural and pericardial, occur concomitantly with myxedema coma. There are cases on literature that describe myxedema associated with minimal pleural effusions but in our case patient had a large unilateral pleural effusion.The pathogenesis of pleural effusion is hypothesized to be related to increased capillary permeability. On our case patient was tachycardic which is unusual for myedematous patient who can not develop tachycardia in response to infection and stress. Myxoedema coma as a true medical emergency requires a multifaceted approach to treatment in critical care settings for mechanical ventilation, cautious warming and treatment of infections. Intravenous thyroid hormone replacement is the mainstay therapy and cortisone until adrenal insufficiency is excluded. Early recognition and therapy of myxedema coma are essential due to high mortality rate approximately 50% despite adequate treatment and it should be initiated even without laboratory confirmation if clinical suspicion remains high.