First year internal medicine resident University of Missouri Kansas City Kansas City, Missouri, United States
Disclosure(s):
David Gonzalez-Sanchez, MD: No financial relationships to disclose
Background: The interplay between thyroid disease and cardiac function is well-described. Thyroid hormone is known to affect heart rate, contractility, and systemic vascular resistance. Evaluating thyroid function is complicated in acute settings. We describe a rare presentation of myxedema coma complicated by cardiogenic shock (CS).
Methods: A 62-year-old male presented with severe hypotension (80/70), stupor, hypothermia (33.8 ºC), acute on chronic systolic congestive heart failure (CHF) (LVEF: 27%), and lower extremity cellulitis in the setting of severe anasarca. Medical history significant for hypothyroidism (HThy), CHF, severe mitral and tricuspid valve regurgitation, and dialysis-dependent end-stage renal disease. He had a similar presentation 4 months prior (TSH: 49). He reported severe depression, fatigability, and medication noncompliance due to difficulty swallowing. He was admitted to the Cardiac Intensive Care Unit for mixed CS (CI: 1.2) and septic shock.
Outcome: Initial resuscitation consisted of pressor and inotrope support, afterload reduction, broad-spectrum antibiotics, and continuous renal replacement therapy (CRRT). The following day endocrinology recommended intravenous levothyroxine due to myxedema coma (TSH: 94, Myxedema Coma Score of 75, >60 is highly probable/diagnostic). After starting thyroid replacement therapy, the patient’s mental status and cardiac index improved (CI: 3), and pressor and inotrope support initially decreased. He continued to require CRRT and had difficulty weaning off pressors and inotropes. Unfortunately, hospitalization was complicated by gastrointestinal bleeding, severe anemia, and thrombocytopenia leading to increased pressor support, multiple blood product transfusions, and worsening cardiac function. Ultimately, palliative care was involved and the patient and family requested transition to comfort care. It is important to note that severe HThy can lead to impaired cardiac function. Recognition of worsening HThy can be challenging as the signs and symptoms may overlap with HF, renal failure, and sepsis.
Conclusion: Prompt evaluation and treatment of severe HThy is important in patients with CS and history of thyroid disease.
