58-year-old man with lethargy and bradycardia
A 58-year-old man is brought to the emergency department by his son due to progressive lethargy and confusion over the past week. The son, a long-haul truck driver, just returned home. The patient has a history of hypertension and type 2 diabetes but has not seen a physician in several years. A chart review from another hospital notes a total thyroidectomy for Graves' disease 20 years ago. Temperature is 34.2°C (93.6°F), heart rate is 48/min, blood pressure is 88/54 mmHg, and respiratory rate is 10/min with an oxygen saturation of 91% on room air. He is obtunded but withdraws from painful stimuli. Physical examination shows a puffy face, dry skin, and delayed relaxation of deep tendon reflexes. Laboratory studies show sodium 119 mEq/L, potassium 4.1 mEq/L, and glucose 68 mg/dL. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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B
Explanation
Clinical Pearl:
In patients with suspected myxedema coma, empiric intravenous glucocorticoids must be administered along with intravenous levothyroxine to prevent precipitating adrenal crisis, as thyroid hormone replacement can accelerate cortisol metabolism.
Explanation:
This patient's presentation with profound hypothermia, bradycardia, altered mental status, hyponatremia, and a history of total thyroidectomy is highly suggestive of myxedema coma. According to endocrine society guidance, the most appropriate next step is immediate treatment with both intravenous levothyroxine to address the severe hypothyroidism and intravenous hydrocortisone. The empiric glucocorticoids are critical because patients with severe, long-standing hypothyroidism may have concomitant adrenal insufficiency, and administering thyroid hormone alone can accelerate cortisol clearance, precipitating a fatal adrenal crisis. Initiating broad-spectrum antibiotics would be appropriate for septic shock, but the presence of severe hypothermia and bradycardia makes sepsis less likely than myxedema coma. While the patient has severe hyponatremia, administering 3% saline is not the primary treatment; the hyponatremia is expected to correct with treatment of the underlying hypothyroidism. Administering intravenous levothyroxine alone is dangerous as it can unmask underlying adrenal insufficiency. Passive rewarming and fluids are supportive measures but do not constitute the definitive and life-saving treatment for myxedema coma.
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