eMedicine Specialties > Endocrinology > Thyroid

Myxedema Coma or Crisis: Differential Diagnoses & Workup

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
Contributor Information and Disclosures

Updated: Aug 5, 2008

Differential Diagnoses

Euthyroid Sick Syndrome
Hypothermia
Hypoventilation Syndromes
Mental Disorders Secondary to General Medical Conditions
Septic Shock

Other Problems to Be Considered

Cerebrovascular accident

Workup

Laboratory Studies

Laboratory values are essential for the workup of myxedema coma/crisis; however, if the condition is suspected, treatment must be initiated immediately without waiting for the results.

  • Free T4 and TSH
    • Free T4 and T3 levels are low or undetectable.
    • The TSH level may be elevated, indicating a primary thyroid disorder.
    • A low or normal TSH level with low levels of T4 and T3 may indicate central (pituitary) hypothyroidism or the suppression of TSH production by severe illness or drugs, such as dopamine or high-dose glucocorticoids. A serum cortisol level should be determined before beginning intravenous steroids.
  • Serum electrolytes and serum osmolality - Hyponatremia with low serum osmolality is common.
  • Serum creatinine - Because of decreased renal perfusion, the levels are usually elevated.
  • Serum glucose - Hypoglycemia is common but may also suggest adrenal insufficiency.
  • Complete blood count (CBC) with differential - Bands and/or a left shift may be the only sign of infection.
  • Creatine kinase (CK) - CK levels are often elevated, and fractionation indicates skeletal (not cardiac) muscle injury unless a myocardial infarction was the precipitating event.
  • Arterial blood gases - Increased P CO2 and decreased P O2 are found.
  • Pan-culture for sepsis

Imaging Studies

  • Chest radiographs - Obtain chest radiographs for all patients. Cardiomegaly, pericardial effusion, congestive heart failure, and/or pleural effusion are observed.

Other Tests

  • Electrocardiogram - Sinus bradycardia, low-amplitude QRS complexes, a prolonged QT interval, and flattened or inverted T waves are noted.

More on Myxedema Coma or Crisis

Overview: Myxedema Coma or Crisis
Differential Diagnoses & Workup: Myxedema Coma or Crisis
Treatment & Medication: Myxedema Coma or Crisis
Follow-up: Myxedema Coma or Crisis
References
Further Reading
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References

  1. Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. Dec 1 2000;62(11):2485-90. [Medline]. [Full Text].

  2. Fliers E, Wiersinga WM. Myxedema coma. Rev Endocr Metab Disord. May 2003;4(2):137-41. [Medline].

  3. Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. Jul-Aug 2007;22(4):224-31. [Medline].

  4. Nicoloff JT, LoPresti JS. Myxedema coma. A form of decompensated hypothyroidism. Endocrinol Metab Clin North Am. Jun 1993;22(2):279-90. [Medline].

  5. Diekman MJ, Harms MP, Endert E, et al. Endocrine factors related to changes in total peripheral vascular resistance after treatment of thyrotoxic and hypothyroid patients. Eur J Endocrinol. Apr 2001;144(4):339-46. [Medline]. [Full Text].

  6. 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. Feb 2004;180(2):347-50. [Medline]. [Full Text].

  7. Rehman SU, Cope DW, Senseney AD, et al. Thyroid disorders in elderly patients. South Med J. May 2005;98(5):543-9. [Medline].

  8. Sheu CC, Cheng MH, Tsai JR, et al. Myxedema coma: a well-known but unfamiliar medical emergency. Thyroid. Apr 2007;17(4):371-2. [Medline].

  9. Yamamoto T, Fukuyama J, Fujiyoshi A. Factors associated with mortality of myxedema coma: report of eight cases and literature survey. Thyroid. Dec 1999;9(12):1167-74. [Medline].

  10. Hylander B, Rosenqvist U. Treatment of myxoedema coma--factors associated with fatal outcome. Acta Endocrinol (Copenh). Jan 1985;108(1):65-71. [Medline].

  11. Jordan RM. Myxedema coma. Pathophysiology, therapy, and factors affecting prognosis. Med Clin North Am. Jan 1995;79(1):185-94. [Medline].

  12. Taguchi T, Iwasaki Y, Asaba K, et al. Myxedema coma and cardiac ischemia in relation to thyroid hormone replacement therapy in a 38-year-old Japanese woman. Clin Ther. Dec 2007;29(12):2710-4. [Medline].

  13. 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(1):R1. [Medline]. [Full Text].

  14. Rimar D, Kruzel-Davila E, Dori G, et al. Hyperammonemic coma--barking up the wrong tree. J Gen Intern Med. Apr 2007;22(4):549-52. [Medline]. [Full Text].

  15. Brent GA, Larsen PR, Davies TF. Hypothyroidism thyroiditis. In: Kronenberg HM, Melmed S, Polonsky KS, et al, eds. Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders/Elsevier; 2008.

  16. Wartofsky L. Myxedema coma. Endocrinol Metab Clin North Am. Dec 2006;35(4):687-98, vii-viii. [Medline].

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Further Reading

Related eMedicine topics:
 Graves Disease [Endocrinology]
Graves Disease [Pediatrics: General Medicine]
Hypothyroidism [Endocrinology]
Hypothyroidism [Pediatrics: General Medicine]
Hypothyroidism and Myxedema Coma
Pretibial Myxedema

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Keywords

myxedema coma, myxedema crisis, hypothyroidism, severe hypothyroidism, decompensated hypothyroidism, pretibial myxedema, Graves disease, Graves' disease, localized dermopathy, thyroid hormones, autoimmune thyroid disease, thyroid ablation therapy, iodine deficiency, thyroxine, T4, triiodothyronine, T3, thyroid-stimulating hormone, TSH, thyrotropin

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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.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Romesh Khardori, MD, Chief, Division of Endocrinology, Metabolism and Molecular Medicine, Professor, Department of Internal Medicine, Southern Illinois University School of Medicine
Romesh Khardori, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society of Andrology, Endocrine Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

CME Editor

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.

 
 
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