Endocrine Abstracts

A 78-year-old Irish male was repatriated from Malawi, where had been an inpatient for a month. His vitals in ED included a T 34.6C, HR 52bpm, GCS of 13/15 (E3V4M6), blood glucose fluctuated (nadir 2.3mmol/l). His weight was 77 kg. His difficult catheterisation yielded a residual volume of 4L. His TSH was 130.23mU/l (0.3–4.2) and fT4 was undetectable. On day two 9AM cortisol was 388nmol/l (160–550). On Saturday (Day3), he deteriorated with a GCS of 10/15 (E3V2M5): he was hypotensive (76/50mmHg), hypoxemic and bradycardic (59bpm), with blood glucose of 4.6mmol/l. His haemoglobin dropped from 90 to 68g/l (130–168), requiring urgent blood transfusion. Prompt treatment also included fluid resuscitation, IV hydrocortisone (100 mg), and IV antibiotics for a suspected HAP/CAUTI. He was transferred to a monitored bed. IV levothyroxine 300 mg was given, followed by IV liothyronine (10 mg twice daily), which was sourced from another hospital. His clinical status rapidly improved following the administration of both thyroid hormones and supportive measures, with his vitals normalising. From Sunday, levothyroxine 100 mg was administered via NG tube. IV liothyronine was continued for three days. Over the weekend IV hydrocortisone was continued at 50 mg four times daily and then reduced to 20 mg thrice daily for two days, then stopped. This case underscores the importance of a high index of suspicion for myxedema coma in patients with unexplained altered mental status, hypothermia and undetectable fT4, serving as a valuable reminder of the challenges in diagnosing and managing this life-threatening endocrine emergency, especially out-of-hours and when a detailed history is unavailable, highlighting the need for both local and national guidelines.