A 63-year-old woman with a history of bipolar disorder and hypothyroidism under section 3 of the Mental Health Act in a psychiatric centre was admitted with severe hypothermia, bradycardia, hypotension and decreased GCS. She was on procyclidine and haloperidol for bipolar disorder and on intravenous antibiotics for 2 days for recurrent cellulitis in her leg. She was on levothyroxine 50 μg daily but was non compliant with her medications.
Thyroid function testing on admission revealed that she was severely hypothyroid with a serum TSH concentration of >99 mIU/l, free T4 of 5.4 pmol/l and free T3 of 1.5 pmol/l. Myxoedema crisis was suspected and she was admitted to ITU for ionotropic support. She was given i.v. liothyronine 50 μg followed by liothyronine 25 μg and hydrocortisone 50 μg three times daily. Oral levothyroxine 100 μg daily was commenced via nasogastric tube on day 3 and i.v. liothyronine and hydrocortisone were tapered and stopped on day 5. The clinical parameters improved and the patient was transferred to a general medical ward on day 4. The serum TSH concentration improved dramatically after administration of levothyroxine, but as the patient continued to be non compliant, she was commenced on oral levothyroxine 700 μg to be administered once a week under supervision.
Myxoedema coma is an uncommon life threatening endocrine crisis usually occurring in the elderly women, precipitated by an acute event such as infection, myocardial infarction, cold exposure, or the administration of sedative drugs. The mortality rate remains very high in these patients. Diagnosis can be delayed in patients with severe sepsis on the background of mental illness. There is no clear guideline about how these patients should be managed. Early diagnosis and management of myxoedema coma by the ITU and Endocrinologists led to a favourable outcome in our patient.