Roux-en-Y to Myxedema Coma

Myxedema Coma (MC) is a life-threatening presentation of hypothyroidism (HT). Bariatric surgeries are used to address obesity and can be complicated by malabsorption. We describe a case of MC due to malabsorption after a Roux-en-Y (RY) surgery revision.

Case Description:

A 50-year-old female presented to the hospital for weakness, nausea, emesis, fatigue, confusion, and constipation for 6 weeks. She had a history of HT and obesity treated with RY 18-years-ago with multiple revisions most recently 9 months prior to presentation. She had a history of poorly controlled HT for several years as records show she had a TSH of 9.090 mIU/ml 2 years before and 15.28 mIU/ml a few months before that. However, she stated she was taking her Lt4 each morning as prescribed.

On arrival, the patient had a blood pressure of 75/50 mmHg, heart rate of 50, and temperature of 36.4 Celsius. Physical exam revealed left lower quadrant abdominal tenderness, generalized weakness, cool skin, trace extremity nonpitting edema, delayed reflexes, and slurred speech. Laboratory evaluation revealed TSH of 66.55 mIU/ml, free T4 of 0.62 ng/dL, and Total T3 < 10.0 ng/dL. Serum cortisol obtained at 21:09 was 15.45 mcg/dL. MC score was 65, consistent with MC.

She was treated with intravenous levothyroxine 250mcg and liothyronine 5mcg. She continued to struggle with oral intake and a nasogastric tube was placed without resolution of nausea and vomiting. After 8 days of treatment her confusion, weakness, and constipation improved thus she was transferred to the hospital where her last RY revision had been performed for gastrojejunal tube placement.

Discussion:

Bariatric surgeries typically decrease total thyroid hormone needs for patients, however, RY procedures cause significant variability in post-operative Lt4 requirements [1]. Thus, it is important to monitor post-operative TSH levels. Patients with HT planning on bariatric surgery should be counseled on the complications this could have for treating their HT. Close monitoring of patient’s TSH should be done afterwards as well as counseling on proper timing/intake of Lt4 doses. Unfortunately, the exact anatomic changes the patient had were unable to be discerned as her surgeries had been performed across multiple hospitals/EMRs/timeframes. However, her case demonstrates MC is a potential complication of RY procedures, reminding clinicians to closely follow patient’s hypothyroidism after surgery.