INTRODUCTION: Myedema coma is a medical emergency requiring prompt recognition and appropriate treatment. This condition often results from uncontrolled long-standing hypothyroidism or triggered by an acute event such as a myocardial infarction, infection, or a variety of systemic illnesses. Symptomology can affect a broad range of systems, including but not limited to hypotension, hypothermia, hypoglycemia, altered mental status, and hyponatremia. In this case report we discuss a case of an unstable patient with myxedema coma presenting with paranoid delusions and cardiac tamponade.CASE PRESENTATION: 66 year old Ethiopian female with hypothyroidism and chronic lymphedema, noncompliant with levothyroxine, presented to the hospital via EMS, due to altered mental status, paranoid outbursts, and a subacute history of visual and auditory hallucinations. Review of symptoms were unable to be obtained due to paranoid delusions and nonsensical speech. Physical exam revealed a temperature of 90.5 degrees Fahrenheit, blood pressure of 64/43mmhg, heart rate of 56 bpm, and she was on three liters nasal canula oxygen. A thyroid goiter, distal heart sounds and pretibial myxedema were present on exam. TSH was 20.26 and free T4 was undetectable. WBC count was 2.5, sodium 135mmol/L, blood glucose 80, with normal renal function. Urine drug screen was negative. Chest x-ray showed an enlarged cardiac silhouette, and an echocardiogram revealed cardiac tamponade. She underwent an emergent pericardiocentesis with removal of more than 1300mL of transudative fluid. She was diagnosed with myxedema coma and treated with IV levothyroxine, liothyronine and hydrocortisone. TSH normalized and the patient was transitioned into oral levothyroxine. Mental status, hemodynamics, and metabolic derangements resolved, and the patient was subsequently discharged with close outpatient follow up.
DISCUSSION:The thyroid gland is intimately involved in the regulation of metabolic and physiologic demands of the living organism. An imbalance could potentially lead to catastrophic multisystem collapse. Myxedema coma is a rare manifestation of hypothyroidism with only 0.1% prevalence (1). Patients present with neuropsychiatric manifestations, hypothermia, cardiovascular collapse and multiorgan failure (1,2). The severity of hypothermia is proportionally related to the risk of mortality.CONCLUSIONS: Cardiac tamponade is a rare cardiac manifestation of hypothyroidism, however prompt recognition, urgent pericardiocentesis, and thyroid hormone replacement therapy are critical in preventing pericardial fluid accumulation and reduction in mortality (2-4).
