Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19

Abstract

SARS-CoV-2 infection is associated with significant lung and cardiac morbidity but there is a limited understanding of the endocrine manifestations of COVID-19. Although, thyrotoxicosis due to subacute thyroiditis has been reported in COVID-19, it is unknown whether SARS-CoV-2 infection can also lead to decompensated hypothyroidism. We present the first case of myxedema coma in COVID-19 and we discuss how SARS-CoV-2 may have precipitated multi-organ damage and sudden cardiac arrest in our patient. A 69-year-old female with a history of small cell lung cancer presented with hypothermia, hypotension, decreased respiratory rate, and a Glasgow Coma Scale score of 5. The patient was intubated and administered vasopressors. Laboratory investigation showed elevated thyroid stimulating hormone, very low free thyroxine, elevated thyroid peroxidase antibody, and markedly elevated inflammatory markers. SARS-CoV-2 test was positive. Computed tomography showed pulmonary embolism and peripheral ground glass opacities in the lungs. The patient was diagnosed with myxedema coma with concomitant COVID-19. While treatment with intravenous hydrocortisone and levothyroxine were begun the patient developed a junctional escape rhythm. Eight minutes later, the patient became pulseless and was eventually resuscitated. Echocardiogram following the arrest showed evidence of right heart dysfunction. She died two days later from multi-organ failure. This is the first report of SARS-CoV-2 infection with myxedema coma. Sudden cardiac arrest likely resulted from the presence of viral pneumonia, cardiac arrhythmia, pulmonary emboli, and myxedema coma – all of which were associated with the patient’s SARS-CoV-2 infection

Coronavirus Disease 2019 and the Thyroid - Progress and Perspectives

“…Management would be more difficult if drug-induced agranulocytosis were to take place (but fortunately not so far reported), or thyroid storm ( 84 ), or myxedema coma were to occur ( 85 ). As shown here, our understanding of the thyroidal manifestation of COVID-19 is far from complete as is the etiologic view of COVID-19 and thyroid insults.…”

Spectrum of Endocrine Dysfunction and Association With Disease Severity in Patients With COVID-19: Insights From a Cross-Sectional, Observational Study

“…SARS-CoV-2 has been proposed to cause direct thyroid dysfunction owing to ACE2 mediated viral entry and destructive thyroiditis (15,16). Though rarely, triggering of autoimmunity and Graves' disease and myxoedema coma have also been reported in COVID-19 patients (18,36).…”

“…However, overall clinical evidence of endocrine involvement in COVID-19 patients is limited (8,(12)(13)(14)(15)(16)(17)(18)(19)(20), mostly confined to case reports and small patient series (15)(16)(17)(18)20). Moreover, some of the patients in these reports had other disorders that could explain their presentation (including adrenal hemorrhage in a COVID-19 patient with APLA syndrome, death in a COVID-19 patient with myxoedema coma) (18,20). The other available body of evidence is extrapolated from studies involving SARS patients, their autopsy data, and retrospective studies in SARS survivors (21)(22)(23).…”

Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects

“…A cases of Hashimoto's thyroiditis (HT) with subclinical hypothyroidism in a 45-year-old Chinese man [47] and a myxedema coma in a 69-year-old woman fatality-case have also been described [48]. Thyroid autoimmunity was certainly a pre-existing and undiagnosed condition, but SARS-CoV-2 probably exacerbated the basal condition in these patients.…”