ODP517 Successful Treatment of Myxedema Coma after SARS-CoV-2 infection with Combination Oral Levothyroxine and Liothyronine

INTRODUCTION: Myxedema coma (MC) is a rare, extreme form of hypothyroidism. It can be triggered by numerous factors including severe illness, trauma and infection. With the emergence of COVID, one may ask if COVID infection can lead to myxedema coma. Prompt infusion of levothyroxine is the consensus treatment. However, in areas where the IV form is unavailable, oral levothyroxine and liothyronine can be an option. CASE: This is a case of a 64-year-old Filipino female with no known comorbidities, no history of neck radiation or thyroid surgery. She was hospitalized for 28 days a month prior to this admission for severe COVID and and was discharged well. One day after discharge, she was noted to have decrease in sensorium with no other apparent cause. On examination, the patient was unresponsive with a blood pressure of 60/40 mmHg, heart rate of 52 bpm, temperature 36°C and oxygen saturation of 96% at 7lpm. Examination of the neck showed no mass or scar, and the rest of systemic exam was unremarkable. Her initial bloodwork showed: Hemoglobin 7 gm/dl, Creatinine 2.4 mg/dl, sodium 132 mmol/L and RBS 66 mg/dl. Thyroid stimulating hormone was 33.26 uIU/mL (NV 0.55 - 4.78 uIU/mL), free thyroxine (T4) level of 0. 07 ng/dl (NV 0.89-1.76 ng/dL) and a random serum cortisol 37.3 ug/dL. Anti-TPO was negative. IV hydrocortisone 100mg was administered until adrenal insufficiency was ruled out. Due to the unavailability of IV formulations, a loading dose of 100mcg of levothyroxine tablet and 25mcg liothyronine tablet was given thru NGT. Intensive supportive care was given. Adjustment of levothyroxine dosage was based on clinical response. The patient responded well to treatment and was discharged improved after 3 weeks. The temporal relationship between the patient's clinical manifestations and her recent infection, in the absence of other risk factors, made the authors consider that her myxedema coma was most likely precipitated by COVID. The proposed mechanism is via the ACE2 receptors highly expressed in the thyroid gland. SARS-CoV-2 hijacks these receptors in order to enter the thyroid, destroy follicular cells and stop the ability to produce T3 and T4. CONCLUSION: Myxedema coma occurs when a precipitating factor disrupts thyroid hormone regulation and it bears a grim prognosis. Among patients with COVID and even those who have recovered, an increased suspicion of hypothyroidism is necessary to diagnose the condition at a stage that is early enough to avoid myxedema coma. In areas where parenteral levothyroxine is not available, this case shows that administration of combination oral levothyroxine and liothyronine for myxedema may be successful. Presentation: No date and time listed