Introduction: Myxoedmea coma is an extreme expression of hypothyroidism with a high mortality rate. It is rarely associated with thyroid lymphoma.
Case report: A 66-year-old lady presented acutely unwell with a two week history of cough and shortness of breath. She was hypothermic, hypoxic with clinical and radiological signs of pneumonia. Her TSH was 99.8 mU/L and T4 less than 5 pmol/L with strongly positive thyroid microsomal antibodies, raised WBC and inflammatory markers. She became more drowsy and was eventually intubated and ventilated, with difficulty. A diagnosis of Myxoedema Coma precipitated by bilateral pneumonia was made. She was treated with ionotropic support, T3 and T4 replacement, strict fluid balance and gradual rewarming. She made a good recovery and was discharged to the ward on 125 μg of thyroxine. She noticed an increase in goitre size with compressive symptoms. Thyroid ultrasound confirmed an enlarged gland with multiple nodules and no tracheal compression. Flow-volume-loops showed external respiratory compression. Multiple Fine needle aspiration was inconclusive. Whilst awaiting a formal biopsy she had a respiratory arrest requiring an emergency tracheostomy. The thyroid tissue taken at the time showed Burkitts lymphoma of the thyroid. Radiological staging confirmed no extrathyroidal evidence of lymphoma. She subsequently received chemotherapy with excellent results and disappearance of the thyroid microsomal antibodies.
Conclusion: Thyroid lymphoma has a well documented association with Hashimotos thyroiditis, but thyroid lymphoma presenting as myxoedema coma is extremely rare with no reports of Burkitts Thyroid lymphoma in the literature. Our case demonstrates the importance of suspecting Thyroid lymphoma in any rapidly growing goitre and that flow-volume-loops are essential in assessing external respiratory compression.