- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with a high mortality rate. Fortunately, it is now a rare presentation of hypothyroidism, likely due to earlier diagnosis as a result of the widespread availability of thyroid-stimulating hormone (TSH) assays.
Early recognition and therapy of myxedema coma are essential. Treatment should be initiated on the basis of clinical suspicion without waiting for laboratory results. Important clues to the possible presence of myxedema coma in a poorly responsive patient are the presence of a thyroidectomy scar or a history of radioiodine therapy or hypothyroidism. A history obtained from family members often reveals antecedent symptoms of thyroid dysfunction followed by progressive lethargy, stupor, and coma.
The clinical presentation, diagnosis, and treatment of myxedema coma will be reviewed here. The diagnosis and treatment of hypothyroidism are reviewed separately.
- Ono Y, Ono S, Yasunaga H, et al. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol 2017; 27:117.
- Santiago R, Rashkin MC. Lithium toxicity and myxedema coma in an elderly woman. J Emerg Med 1990; 8:63.
- Waldman SA, Park D. Myxedema coma associated with lithium therapy. Am J Med 1989; 87:355.
- Mazonson PD, Williams ML, Cantley LK, et al. Myxedema coma during long-term amiodarone therapy. Am J Med 1984; 77:751.
- Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med 2007; 22:224.
- Westphal SA. Unusual presentations of hypothyroidism. Am J Med Sci 1997; 314:333.
- Mavroson MM, Patel N, Akker E. Myxedema Psychosis in a Patient With Undiagnosed Hashimoto Thyroiditis. J Am Osteopath Assoc 2017; 117:50.
- Jansen HJ, Doebé SR, Louwerse ES, et al. Status epilepticus caused by a myxoedema coma. Neth J Med 2006; 64:202.
- Fjølner J, Søndergaard E, Kampmann U, Nielsen S. Complete recovery after severe myxoedema coma complicated by status epilepticus. BMJ Case Rep 2015; 2015.
- Haupt M, Kurz A. Reversibility of dementia in hypothyroidism. J Neurol 1993; 240:333.
- Iwasaki Y, Oiso Y, Yamauchi K, et al. Osmoregulation of plasma vasopressin in myxedema. J Clin Endocrinol Metab 1990; 70:534.
- Zwillich CW, Pierson DJ, Hofeldt FD, et al. Ventilatory control in myxedema and hypothyroidism. N Engl J Med 1975; 292:662.
- Lee, CH, Wira, CR. Am J Emerg Med 2009; 27:1021.
- Klein I. Thyroid hormone and the cardiovascular system. Am J Med 1990; 88:631.
- Shenoy MM, Goldman JM. Hypothyroid cardiomyopathy: echocardiographic documentation of reversibility. Am J Med Sci 1987; 294:1.
- Bigos ST, Ridgway EC, Kourides IA, Maloof F. Spectrum of pituitary alterations with mild and severe thyroid impairment. J Clin Endocrinol Metab 1978; 46:317.
- Popoveniuc G, Chandra T, Sud A, et al. A diagnostic scoring system for myxedema coma. Endocr Pract 2014; 20:808.
- HOLVEY DN, GOODNER CJ, NICOLOFF JT, DOWLING JT. TREATMENT OF MYXEDEMA COMA WITH INTRAVENOUS THYROXINE. Arch Intern Med 1964; 113:89.
- Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670.
- MacKerrow SD, Osborn LA, Levy H, et al. Myxedema-associated cardiogenic shock treated with intravenous triiodothyronine. Ann Intern Med 1992; 117:1014.
- Arlot S, Debussche X, Lalau JD, et al. Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care Med 1991; 17:16.
- Wartofsky L. Myxedema coma. In: The Thyroid: A Fundamental and Clinical Text, Braverman LE, Utiger RD (Eds), Lippincott, Williams & Wilkins, Philadelphia 2000. p.843.
- Yamamoto T, Fukuyama J, Fujiyoshi A. Factors associated with mortality of myxedema coma: report of eight cases and literature survey. Thyroid 1999; 9:1167.
- Hylander B, Rosenqvist U. Treatment of myxoedema coma--factors associated with fatal outcome. Acta Endocrinol (Copenh) 1985; 108:65.
- Ladenson PW, Goldenheim PD, Ridgway EC. Rapid pituitary and peripheral tissue responses to intravenous L-triiodothyronine in hypothyroidism. J Clin Endocrinol Metab 1983; 56:1252.
- Zaninovich AA, el Tamer E, el Tamer S, et al. Multicompartmental analysis of triiodothyronine kinetics in hypothyroid patients treated orally or intravenously with triiodothyronine. Thyroid 1994; 4:285.
- Rodríguez I, Fluiters E, Pérez-Méndez LF, et al. Factors associated with mortality of patients with myxoedema coma: prospective study in 11 cases treated in a single institution. J Endocrinol 2004; 180:347.
- Dutta P, Bhansali A, Masoodi SR, et al. Predictors of outcome in myxoedema coma: a study from a tertiary care centre. Crit Care 2008; 12:R1.
- Beynon J, Akhtar S, Kearney T. Predictors of outcome in myxoedema coma. Crit Care 2008; 12:111.
- Salomo LH, Laursen AH, Reiter N, Feldt-Rasmussen U. Myxoedema coma: an almost forgotten, yet still existing cause of multiorgan failure. BMJ Case Rep 2014; 2014.
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL PRESENTATION
- Neurologic manifestations
- Cardiovascular abnormalities
- When to suspect the diagnosis
- Laboratory evaluation
- Thyroid hormone
- - Choice of therapy
- - Dosing
- - Monitoring
- - Potential risks
- Supportive measures
- SUMMARY AND RECOMMENDATIONS