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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 76-78

Pediatric Myxedema Coma – presenting as Surgical Abdomen


1 Associate professor and head of PICU, Department of pediatric critical care, Indira Gandhi Institute of child health, Bangalore, India
2 Fellow in pediatric critical care, Department of pediatric critical care, Indira Gandhi Institute of child health, Bangalore, India
3 Second year post graduate in Pediatrics, Indira Gandhi Institute of Child Health, Bangalore, India

Date of Submission07-Mar-2018
Date of Acceptance10-Apr-2018
Date of Web Publication30-Apr-2018

Correspondence Address:
H S Vinayaka
Fellow in pediatric critical care, Department of pediatric critical care, Indira Gandhi Institute of child health, South Hospital Complex, Dharmaram College post, Bangalore 560029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.21304/2018.0502.00379

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  Abstract 


Myxedema com, also called myxedema crisis is a rare life threatening clinical condition that represents severe hypothyroidism. It may be the initial presentation in pediatric patients with prolonged untreated hypothyroidism. Myxedema coma should be suspected in pediatric patients with altered mental status, hypothermia and cardiovascular instability. This condition is fatal without treatment. Thyroid replacement should be initiated as early as possible. Early intervention in hypothyroid patients and in patients where hypothyroidism is suspected has shown to prevent morbidity and mortality associated with myxedema crisis.

Keywords: Myxedema, coma, Pediatric, surgical abdomen


How to cite this article:
Basavaraj G V, Vinayaka H S, Sugumar K. Pediatric Myxedema Coma – presenting as Surgical Abdomen. J Pediatr Crit Care 2018;5:76-8

How to cite this URL:
Basavaraj G V, Vinayaka H S, Sugumar K. Pediatric Myxedema Coma – presenting as Surgical Abdomen. J Pediatr Crit Care [serial online] 2018 [cited 2020 Mar 29];5:76-8. Available from: http://www.jpcc.org.in/text.asp?2018/5/2/76/281126




  Introduction Top


Myxedema is a term used to denote severe hypothyroidism. Myxedema coma (MC) is an extreme complication of hypothyroidism with a incidence of 0.22 cases per million people per year.[1] MC is a life threatening emergency with mortality as high as 60%.[2] MC occurs as a result of long standing undiagnosed or undertreated hypothyroidism .Primary hypothyroidism accounts for more than 95% of cases and 5%accounts to hypothalamic or pituitary causes.[3] It is usually precipitated by a systemic illness. MC usually presents as hypothermia, bradycardia, hypotension, congestive heart failure, altered mental function and as coagulopathy.[4] Other organ systems including pulmonary, renal and gastric are also affected. Levothyroxine is recommended as the preparation of choice for treatment of hypothyroidism. Iniation of treatment has shown good outcomes in affected patients.[5] We present a 13 year old female a case of MC with initial presentation as a surgical abdomen.


  Case Report Top


A 13 year old female presented to the emergency department with complaints of abdominal distension, vomiting and not passed stools for 2 days, alterec sensorium for 1 day. At admission, child was in hypotensive shock, prolonged capillary refill time, cold peripheries and oxyhemoglobin saturation of 90% in room air. Following stabilisation with fluid boluses and ionotropic support, general examination revealed short stature, dry scaly skin over extremities, puffiness of face and legs and abdominal distension. Systemic examination revealed distended abdomen and diffuse tenderness. She was lethargic but responding to oral commands. Cardiac auscultation showed muffled heart sounds. Lungs were clear. Investigations revealed haemoglobin of 10g/dl, white cell counts of 33700 cells/cu mm, platelet of 1.19 lakh with prolonged prothrombin time and activated partial thromboplastin time. Liver enzymes were grossly elevated (SGOT- 3451, SGPT- 1326). Peripheral smear showed macrocytic anemia. Renal function was normal. X-ray abdomen showed gas filled bowel loops. Ultrasonogram abdomen also revealed the same. Child was also having persistent hypoglycaemia.

The patient was electively ventilated in view of fluid refractory and catecholamine resistant shock. She was being treated as suspected intestinal obstruction / sepsis with intravenous antibiotics. In view of short stature, dry scaly skin and delay in attainment of secondary sexual characters, with present clinical scenario we thought of MC. Thyroid profile was sent, which revealed elevated thyroid stimulating hormone and low free and total T4. Free T4 being 0.28ng/dl, total T4 was 2.38 mcg/dl, thyroid stimulating hormone was 132 mIU/ml. Hence patient was diagnosed with myxoedema coma complicated with multiorgan failure. She was started with T.Thyroxine, but the patient expired due to refractory shock and disseminated intravascular coagulation.


  Case Discussion Top


Myxedema coma is a severe form of hypothyroidism and is usually life threatening.[1] MC occurs on the background of underlying precipitating factors like infection, septicaemia, cerebrovascular accidents, gastrointestinal bleeding and use of sedative drugs.[1] Discontinuation of thyroid supplements in critically ill patients had also been implicated in its causation. The main pathogenesis is due to low intracellular T3, which leads to hypothermia, reduced cardiac activity, altered vascular permeability. Clinical presentation includes hypothermia, hypoglycaemia, altered mental status, lethargy, cardiac dysfunction manifesting as bradycardia, bundle branch blocks, complete heart blocks, polymorphic ventricular tachycardia, and arrhythmias.[2] Other features include pericardial and pleural effusion, hemotologic manifestations like macrocytic anemia, prolonged bleeding and clotting time, decreased platelet adhesiveness secondary to decreased von willebrand factor synthesis. Our patient presented as abdominal distension, vomiting and not passed stools suggesting a surgical abdomen initially. She was diagnosed and treated as suspected intestinal obstruction /sepsis.

WInvestigations should be based on individual clinical presentation. White cell counts, urine routine and and microscopy, blood and urine culture, serum electrolytes, and chest x-ray and electrocardiogram should be obtained. Laboratory abnormalities include low free thyroxine and serum TSH. Serum TSH may be normal or low in case of central hypothyroidism.[2] Others include anemia, hypernatremia, elevated liver enzymes, altered renal function test, abnormal coagulation profile, hyperhomocysteinemia, hyper cholestrolemia.[7] Our patient had findings suggestive of end organ damage like elevated liver enzymes, raised creatinine, and altered coagulation profile. X-ray abdomen showed multiple air filled bowel loops.

Treatment consists of immediate resuscitative measures as it is a lethal medical emergency. Thyroid hormone replacement is vital for survival of these patients. Levothyroxine should be based on body surface area as 100mcg/m2/d[2]. Therapeutic effect in MC shows improved mental status, improved cardiac and pulmonary function. Hence treatment must be initiated without delay even on the grounds of suspicion. Intravenous thyroxine should be initiated as soon as possible. Oral thyroxine replacement has also shown improvement in patients where intravenous levothyroxine is not available.

Figure 1: x ray abdomen showing dilated bowel loops. Mimicking surgical abdomen

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Conflict of Interest - Ni



 
  References Top

1.
Mathew V, Misgar RA, Ghosh S, et al.Myxedema coma : a new look into an old crisis. J Thyroid Res 2011;2011:493462.  Back to cited text no. 1
    
2.
Zhu yueniu, Wenjuan, Mengyan et al. Myxedema coma : a case report of pediatric emergency care. Medicine 2017; 96:21(e6952)  Back to cited text no. 2
    
3.
Wartofsky L. Myxedema coma . Endocrinol Metab Clin North Am 2006;35:687-98.  Back to cited text no. 3
    
4.
Root JM , Vargas M, Garibaldi LR. Pediatric patient with altered mental status and hypoxemia:case report. Pediatric Emergency care 2016; doi:10.1097/PEC.00000000000000722.  Back to cited text no. 4
    
5.
Jonklaas J, Bianco AC, Bauer AJ. Guidelines for the treatment of hypothyroidism: prepared by the American thyroid association task force on thyroid hormone replacement. Thyroid 2014 :24:1670-751.  Back to cited text no. 5
    
6.
Nicoloff JT, LoPresti JS. Myxedema coma: a form of decompensated hypothyroidism, Endocrinology and Metabolism clinics of North America 1993;22(2):279-90.  Back to cited text no. 6
    
7.
Roberts CG, Ladenson PW. Hypothyroidism. Lancet 2004; 363:793-803.  Back to cited text no. 7
    
8.
Weisinga WM. Hypothyroidism and Myxedema coma in Endocrinology Adult and Pediatric, J.L.Jameson and L.J.Legroot, Eds, saunders, Philadelphia,Pa, USA,6th edition, 2010.  Back to cited text no. 8
    


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