Myxedema Coma or Crisis Clinical Presentation

  • Author: Elena Citkowitz, MD, PhD, FACP; Chief Editor: George T Griffing, MD   more...
 
Updated: Nov 23, 2011
 

History

  • Although most patients with myxedema coma/crisis have a long history of hypothyroidism, undiagnosed or undertreated myxedema coma/crisis may be the initial manifestation of a hypothyroid state.
  • A history of generalized fatigue, cold intolerance, constipation, and dry skin (common features of long-standing hypothyroidism) are usually present. These features slowly progress to lethargy, delirium, or coma.
  • Faster progression may occur, precipitated by overmedication, stroke, congestive heart failure, trauma, exposure to cold environmental temperatures, or an infection, such as pneumonia.
  • Relatives or friends who know the patient may be able to report a history of long-standing fatigue, weight gain, hair and skin changes, edema, constipation, and cold intolerance.
  • Most cases of myxedema coma/crisis occur during the winter in women aged 60 years or older, although a case of a woman presenting in labor has been reported.
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Physical

  • Hypothermia is usually present in myxedema coma/crisis. If mercury thermometers are used, the degree of hypothermia may not be recognized unless the temperature of the thermometer is lowered before checking the patient's temperature. Moreover, use of special thermometers that record well below 90°F may be necessary in order to determine the patient's actual temperature and to monitor rewarming.
  • Absence of fever in the presence of infection can be expected.
  • The following features are extremely common, although some are not invariably present:
    • Hypotension/shock
    • Hypothermia
    • Decreased pulse pressure, normal systolic pressure, elevated diastolic pressure, slow pulse and respiration rates
    • Periorbital, nonpitting edema; facial swelling or coarseness; macroglossia; enlargement of the tonsils, nasopharynx, and larynx; coarse or thinning hair[9]
    • Thyroid - Enlarged, not palpable, scar suggesting previous thyroidectomy
    • Lungs - Slow respiration rate, hypoventilation, congestion, pleural effusions, consolidation
    • Heart - Soft or distant heart sounds, diminished apical impulse, bradycardia, enlarged heart, pericardial effusion
    • Abdomen - Distension secondary to ileus and/or ascites, diminished or absent bowel sounds
    • Bladder distension
    • Extremities - Cold, nonpitting edema of the hands and feet
    • Skin/nails - Cool, pale, dry, scaly, thickened skin; dry, brittle nails; ecchymoses, purpura, sallowness due to carotenemia
    • Neuromuscular - Confusion, stupor, obtundation, coma, slow speech, seizures, reflexes with a slow relaxation phase
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Causes

Myxedema coma/crisis is a physiologic decompensation of severe primary or secondary hypothyroidism that is usually caused by additional physiologic stress. Specific types of such stress are as follows:

  • Infection/systemic illness
  • Cold environmental temperatures
  • Trauma
  • Burns
  • Decreased cerebral blood flow/cerebrovascular accident
  • Decreased cardiac output/congestive heart failure
  • Respiratory acidosis (increased P CO2 , decreased P O2 )
  • Drugs
    • Tranquilizers
    • Sedatives
    • Anesthetics
    • Analgesics/narcotics
    • Amiodarone
    • Rifampin
    • Beta blockers
    • Lithium
    • Phenytoin
    • Diuretics
  • GI hemorrhage
  • Hypoglycemia
  • CO 2 retention
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Contributor Information and Disclosures
Author

Elena Citkowitz, MD, PhD, FACP  Clinical Professor of Medicine, Yale University School of Medicine; Director, Cholesterol Management Center, Director, Cardiac Rehabilitation, Department of Medicine, Hospital of St Raphael

Elena Citkowitz, MD, PhD, FACP is a member of the following medical societies: American College of Physicians, American Heart Association, National Lipid Association, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephanie L Lee, MD, PhD  Associate Professor, Department of Medicine, Boston University School of Medicine; Director of Thyroid Health Center, Associate Chief, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Fellow, Association of Clinical Endocrinology

Stephanie L Lee, MD, PhD is a member of the following medical societies: American College of Endocrinology, American Thyroid Association, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Romesh Khardori, MD, PhD, FACP  Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, and Endocrine Society

Disclosure: Nothing to disclose.

Mark Cooper, MBBS, PhD, FRACP  Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

References

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