Myxoedema coma is a rare Endocrine emergency.
Case report: 28 year old Polish woman, recently travelled to the UK, presented to the A&E with 3 week history of breathlessness and bilateral leg swelling. She had a history of Trisomy 21, was not taking any medications. She had amenorrhoea for 4 months and orthopnoea with periorbital oedema with conjunctival congestion. Saturation 70% on air, 96% on 15 l of oxygen, heart rate 42, blood pressure 103/61, temperature 36.2. Echocardiogram showed 3.3 cm pericardial effusion and tests showed TSH >100 mIU/l (0.44.4) with FT4 0.05 pmol/l (1222). She initially had type 1 respiratory failure and required intubation and ventilation. Pericardial effusion was drained twice. She was treated with intravenous liothyronine and hydrocortisone along with levothyroxine via nasogastric tube. A CT pulmonary angiogram showed bilateral lower zone collapse and complete collapse of the left upper lobe with widespread ground-glass consolidation throughout the remaining aerated lung with an element of congestive failure. Despite pericardial drainage, she later developed type 2 respiratory failure and despite intubation and ventilation required transfer for surgical tracheostomy and long wean from ventilation. She was discharged on oral levothyroxine and nocturnal CPAP.
Discussion: Our patient had large pericardial effusion and respiratory failure, both rare complications of severe myxoedema. Pericardial effusion is described in literature as a complication of myxoedema. These usually are exudative with high cholesterol content, but can occasionally be transudative. Respiratory failure is well recognised in myxoedema with reduced ventilatory response to carbon dioxide, decreased diffusion capacity, respiratory muscle weakness and decreased breathing capacity. Abnormalities suggestive of fibrotic lung disease have been described. Ventilatory response usually improves after treatment. In our patient, this did not happen and it took over two months to wean her off. Ground glass consolidation and hypoxia requiring prolonged ventilation and tracheostomy is very rare.