Is oral levothyroxine as effective as its intravenous form in myxoedema crisis with catecholamine‐refractory shock?

Abstract

A 3-month-old female infant, born to non-consanguineous parents at 36 weeks of gestation with a birthweight of 2.5 kg, presented with complaints of poor feeding and lethargy of 3 days duration and recurrent apnoeic episodes for 1 day. At presentation, she had apnoea and hypotensive shock, requiring resuscitation with endotracheal intubation, mechanical ventilation, multiple crystalloid boluses followed by epinephrine and norepinephrine infusions. Hypoglycaemia was noted at presentation needing dextrose boluses and infusion. On examination, the baby had sinus bradycardia (68 beats per minute) and hypothermia (33.5 C). Wide-open anterior fontanelle, coarse facies, microcephaly (head circumference 34 cm (À6.29z)), and generalised pitting oedema were remarkable. There was no neck swelling. Anthropometry showed severe underweight (weight 2.5 kg (À4.29z)), severe stunting (height 45 cm (À5.67z)), and no wasting (weight for height 0.49z), suggestive of significant failure to thrive. A detailed neurological examination revealed generalised hypotonia. The examination of other systems was non-contributory. Empirical intravenous antibiotics (cefotaxime and amikacin) were started for suspected sepsis. Investigations revealed microcytic hypochromic anaemia (haemoglobin 72 g/L (normal range: 105-140 g/L)), leucocytosis (white blood cells = 25.2 Â 10 9 /L (normal range: 6.0-14.0 Â 10 9 /L)), and thrombocytosis (platelet count = 662 Â 10 9 /L (normal range: 150-400 Â 10 9 /L)) and hypoalbuminaemia (serum albumin DiscussionMC is a condition with high mortality. 1 The guidelines for the management of MC in children are not well established. 2 MC in Key Points1 Oral levothyroxine is effective in myxoedema crisis with shock. 2 Treatment with intravenous hydrocortisone (or suitable steroids) should precede levothyroxine to avoid cortisol deficiency which can lead to worsening of shock. 3 Thyroid nodules may not be clinically palpable in infants. However, they can be found on imaging (neck ultrasonography).

Levothyroxine: Conventional and Novel Drug Delivery Formulations

“…In the absence of IV injection, the nasogastric route of oral preparation is an alternative for hypothyroid crisis ( 242 ).…”