Endocrine Fellow Creighton University Omaha, Nebraska, United States
Introduction: Myxedema coma is a rare ramification of untreated hypothyroidism with high mortality. Hypothyroid patients can also get serous cavity effusions due to high capillary permeability. Here we report a rare case of myxedema coma and polyserositis.
Case Description: A 29-year-old female patient with untreated Hashimoto’s hypothyroidism presented with dizziness, bloating, nausea, and vomiting which started gradually 1 month prior to presentation. She also had a 3-year history of irregular menstruation that progressed to continuous vaginal bleeding with blood clots. Initial work up was significant for a Hemoglobin of 5.0 gm/dl (ref: 12.0-16.0 gm/dl). CT Thorax/Abdomen/Pelvis revealed a right-sided pleural effusion, a small pericardial effusion, ascites, a 30 x 28 cm cystic mass filling the abdomen and pelvis and a left-sided hydronephrosis with a 19 mm stone at the left ureteropelvic junction. The patient was taken for bilateral ureteric stent placement and uterine D&C under general anesthesia. Thyroid Functions were available after the procedure; TSH: 298 UIU/ml (ref: 0.400-3.800 UIU/ml) and FT4: 0.2 ng/dl (ref: 0.7-1.4 ng/dl). She developed myxedema coma and acute respiratory distress syndrome postoperatively and was started on IV levothyroxine and hydrocortisone. Thoracentesis showed an exudative fluid and reactive mesothelial, inflammatory cells and no malignant cells on cytology. US-Guided drainage of 3.7 L serosanguinous fluid of the cystic pelvic mass showed rare atypical, mesothelial, and mixed inflammatory cells on cytology. Endometrial biopsy was malignancy-free. Unfortunately, she deteriorated over the course of several-day hospital stay and developed cardiopulmonary arrest resulting in death.
Discussion: Myxedema coma occurs in severe hypothyroidism. Precipitating factors might include infection, surgery, anesthetics, and narcotics. In our case, the long-standing, untreated, hypothyroidism followed by the stress of surgery and administration of general anesthesia could have precipitated myxedema coma. Mortality rate can be as high as 30-60%. Thus, a high index of suspicion is key. Transudative pericardial effusion in hypothyroidism have been attributed to increased vascular permeability which, on occasions, might lead to cardiac tamponade. Polyserositis; inflammatory effusions of different serous membranes can be associated with autoimmune diseases or idiopathic. Another concomitant autoimmune disease remains a possibility in our patient. There are only 2 cases reported in the literature in which myxedema coma and severe hypothyroidism were associated with polyserositis. To conclude, we reported an unfortunate case of myxedema coma with a rare association of polyserositis.