Endocrine Abstracts

A 61 year old female was admitted with cough, shortness of breath and bilateral leg oedema. She had type 2 respiratory failure on arterial blood gas and was treated as infective exacerbation of possible underlying chronic obstructive pulmonary disease with nebulisations, antibiotics and steroids. She required non-invasive ventilation in high dependency unit for type 2 respiratory failure. In view of her persistent bradycardia, hypotension and hyponatraemia (Na: 116 mmol/l (133-146)), thyroid function was done which showed severe hypothyroidism with free T4 <3.2 pmol/l (7.7-20.6) and TSH 38.15 mIU/l (0.30-4.80). Thyroid peroxisomal antibody was 704.3 IU/ml (<9.0). Random cortisol was 1484 nmol/l. ECG showed sinus bradycardia with low voltage QRS complexes. CTPA showed no pulmonary embolism but pericardial effusion up to 0.8 cm and small left-sided pleural effusion. Echocardiogram showed 10 mm pericardial effusion. She was started on Liothyronine and Levothyroxine which improved her bradycardia, hypotension and hyponatremia. She was discharged after her condition improved and has been followed up in Endocrinology clinic. Liothyronine has been tapered and stopped. Levothyroxine dose has been titrated. She is now symptom free and her current thyroid function is normal on Levothyroxine. This case highlights the diagnostic challenges in identifying severe hypothyroidism (myxoedema) in an acutely unwell patient and recognising its potential role as a contributing cause of respiratory failure. This patient had underlying severe hypothyroidism due to chronic autoimmune thyroiditis and possible underlying chronic obstructive pulmonary and presented with type 2 respiratory failure. The management consisted of treating her COPD and type 2 respiratory failure with medical therapy and non-invasive ventilation and replacement of thyroid hormones.