Myxedema Coma

  • Myxedema coma is an extreme complication of hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration
  • Precipitating factors include poor adherence to daily thyroid hormone replacement therapy, stroke, heart failure, myocardial infarction, infection, metabolic disturbances, cold exposure, trauma, gastrointestinal bleeding, acidosis, and hypoglycemia
  • Multiple organ systems are affected:
    • Hypoventilation leading to hypercapnia and hypoxemia
    • Bradycardia and hypotension
    • Hyponatremia
    • Hypoglycemia
  • Two most common findings are hypothermia and mental status changes
  • Mortality rate of myxedema coma is over 20%
  • Physical exam findings: altered mentation, bradycardia, delayed reflex relaxation, dry/cool skin, myxedematous face, constipation, abdominal distension
  • If myxedema coma is suspected, the TSH and free T4 levels should be checked promptly, but is a clinical diagnosis
  • Intravenous levothyroxine has traditionally been administered, with an initial bolus of 200 to 500 micrograms followed by daily doses between 50 and 100 micrograms until transition to oral administration is feasible
  • May consider lower doses in patients with significant cardiac history to avoid cardiac irregularities
  • Concurrent treatment with high-dose glucocorticoids (such as hydrocortisone) is recommended until adrenal insufficiency is excluded and appropriate adrenal function is confirmed
  • Also treat underlying condition that may have contributed to this: infection, bleeding, hypoglycemia

Cryptococcal Meningitis- Thinking Beyond HIV

This week at morning report we talked about cryptococcal meningitis with Dr. James Luby from UTSW ID Division. Typically associated with HIV, Dr. Luby told us that there are conditions that can be associated with this infection such as liver disease like cirrhosis, end stage renal disease, and diabetes. A study was published in 2011 in Yonsei Medical Journal which was a retrospective look at patients with and without HIV who had diagnosed cryptococcal meningitis. Their findings included:

  • 20 total patients included in the study, 11 of which had HIV
  • Single center study at Pusan National University College of Medicine in South Korea
  • Other conditions were diabetes, end stage renal disease, and liver disease
  • There was no significant difference in mortality between HIV and non-HIV patients
  • No statistically significant differences in serum CRP level and other cerebrospinal fluid parameters between patients with HIV and without HIV

Below is some basic management points for cryptococcal meningitis courtesy of The Hopkins ABX Guide:

  • Diagnosis: positive fungal culture or cryptococcal antigen in CSF
  • CSF cryptococcal Ag positive >95% (serum-100%), India ink positive stain in CSF – 75%, CSF fungal culture>95%
  • Typical CSF profile: protein 30-150mg/dL, monocytes 0-100, Opening pressure>200mmH2) in 75% of cases
  • Treatment
    • Induction Phase: Amphotericin B + flucytosine >14 days and then fluconazole
    • Maintenance Regimen: Fluconazole 200mg/daily PO indefinitely unless CD4>200 for 3 months or 12 months minimum in non-HIV patients and asymptomatic
    • If opening pressure >250mmH2), CSF drainage until <200mmH2O or >50% reduction, repeat daily until OP stable
    • Consider LP or VP shunt if elevated pressures persist

Check out the study below and the IDSA guidelines for management of cryptococcal disease:

Cryptococcal meningitis in patients with or without human immunodeficiency virus: experience in a tertiary hospital

2010 IDSA Guidelines for Management of Cryptococcal Disease

(Image courtesy of Jennifer Lodge)