1. Endocrinology
Ahad Lodhi, M.D.
7/21/2010

2. Case Presentation
• 47 yo CM presented to office with Complain of falls,
leg edema and pain, fatigue, drowsiness, headaches,
shortness of breath, drowling from angle of mouth,
and weight gain.
• Headache mostly on left, for 2 yrs since he was it in the
head with a gun during mugging.
• Falls, mostly on rt side, resurrent, no loss of
concoiusness, no jerky movements, no trauma
• Leg swelling & pain, started 3 yrs ago, gradual, worst
when standing for a long time, worst with drinking
soda.
• Cannot sleep in bed and sleeps in chair.

3. Case Presentation
Review of Systems
General : sweats, anorexia, fatigue, weakness, malaise, and sleep disorder.
Eyes : blurring, halos, discharge, and light sensitivity.
ENT nosebleeds.
CV difficulty breathing at night, near fainting, chest pain or discomfort, racing/skipping heart beats,
fatigue, lightheadedness, shortness of breath with exertion, palpitations, swelling of hands or
feet, difficulty breathing while lying down, and leg cramps with exertion.
Resp sleep disturbances due to breathing, shortness of breath, chest discomfort, and excessive
snoring.
GI loss of appetite, gas, abdominal bloating, and change in bowel habits.
GU urinary frequency and nocturia.
MS muscle cramps, joint pain, joint swelling, back pain, stiffness, muscle weakness, arthritis, loss
of strength, and muscle aches
Derm excessive perspiration, night sweats, dryness, changes in color of skin, flushing, and rash.
Neuro poor balance, headaches, disturbances in coordination, numbness, inability to speak,
falling down, tingling, brief paralysis, visual disturbances, weakness, and excessive daytime
sleeping.
Psych anxiety, depression, thoughts of violence, and frightening visions or sounds.
Endo cold intolerance, heat intolerance, and weight change.
Heme skin discoloration .

4. Case Presentation
PMH:
Hypertension
Thyroid Disorder-Hypothyroidism 1998
Night terrors
Sinusitis
Medications
• LASIX 40 MG TAB 1 Tab by mouth daily
• SYNTHROID 0.15 MG TAB 1 Tab by mouth daily
Pt ran out of it few months ago.
• ADVIL 500 MG

5. Case Presentation
Social History:
Past Surgical History:
Patient currently not sexually active
Thyroidectomy 2/98
Uses condoms when active
Shoulder 1/2004
No H/O STDs
Hospitalization at winchester due to MVA
has never been tested for HIV
H/o Sexual abuse/Physical abuse/Verbal
Abuse
Family History:
Lives at a house with roommates
FH Diabetes
Unemployed
FH Heart Disease, Mother, Sister
is a college Graduate
Family History of Angina
FH Hypertension
FH Stroke
FH Cancer Father, Mother
FH Alzheimers, Mother
FH Suicide, Sister

6. Examination
General: • BMI:49.20, O2 Sat: 94 %
well developed, well nourished, in acute
• Pulse rate:70 / minute
distress. obese, poor hygeine, and unkempt.
Head: • BP: 148 / 90
normocephalic and atraumatic. Msk:
Eyes: unsteady gait.
PERRL/EOM intact, conjunctiva and sclera Pulses:
clear with out nystagmus. UE 2+
Ears: LE Not palpable
canals clear, tympanic membranes intact, Extremities:
no fluid. 4+ edema pitting/nonpitting BL Lower Ext
Nose: upto knees, 4+ edematous/Swollen feet
no deformity, discharge, inflammation, or
lesions. Cervical Nodes:
Mouth: no significant adenopathy.
Drooling from right angle of mouth Psych:
Neck: depressed affect, anxious, and easily
supple, no masses, tenderness or distracted.
enlargement. enlarged thyroid. episodes of crying during the interview

7. Examination
Lungs:
clear bilaterally to auscultation. no
intercostal retractions or use of accessory
muscles. no rales, rhonchi or wheezes.
accessory muscle usage.
Heart:
regular rate and rhythm, S1, S2 without
murmurs, rubs, or gallops.
Abdomen:
soft,non-distended, positive bowel sounds,
no tenderness.
Neurologic:
no focal deficits, cranial nerves II-XII grossly
muscle strength . Slurred Speech, Reflexes not
appreciable.

8. Labs & Imaging
SODIUM 139 MMOL/L 135-146
POTASSIUM 4.4 MMOL/L 3.5-5.1
CHLORIDE 98 MMOL/L 96-106
CO2 [H] 33 MMOL/L 24-32
! ANION GAP 8 MMOL/L 5-16
GLUCOSE 70 MG/DL 70-110
BUN [H] 25 MG/DL 10-20
CREATININE 1.3 MG/DL 0.7-1.3
CALCIUM 9.1 MG/DL 8.5-10.5
AST 29 U/L 15-37
ALT 31 U/L 25-65
ALK PHOS 78 U/L 50-136
TOT PROTEIN 7.8 G/DL 6.5-8.0
ALBUMIN 4.9 G/DL 3.4-5.0
BILI,TOTAL 0.4 MG/DL 0.0-1.0

9. Labs & Imaging

10. Labs & Imaging
CT Scan:
There is no evidence for acute intracranial hemorrhage or mass effect.
Stable appearance of the ventricles and sulci when compared to prior
study dated 3 December 2008.

11. Labs & Imaging
CT Scan:
There is no evidence for acute intracranial hemorrhage or mass effect.
Stable appearance of the ventricles and sulci when compared to prior
study dated 3 December 2008.
CXR
No acute pulmonary process.

12. Labs & Imaging
CT Scan:
There is no evidence for acute intracranial hemorrhage or mass effect.
Stable appearance of the ventricles and sulci when compared to prior
study dated 3 December 2008.
CXR
No acute pulmonary process.
Echo
Limited but Probably
Normal Study

13. Labs & Imaging
CT Scan:
There is no evidence for acute intracranial hemorrhage or mass effect.
Stable appearance of the ventricles and sulci when compared to prior
study dated 3 December 2008.
CXR
No acute pulmonary process.
TSH
Echo
56.800 uIU/mL
Limited but Probably 0.350-5.50
Normal Study
T3, Total
<40 NG/DL 60-181

14. Diagnosis

15. Diagnosis
Severe Hypothyroidsm

16. Topic
Myxedema Coma &
Hypothyroidsm

17. Myxedema Coma: Decompansated
Hypothyroidsm
Myxedema coma is a loss of brain function as a result of severe,
longstanding low level of thyroid hormone in the blood
(hypothyroidism). It is considered a life-threatening
complication of hypothyroidism and represents the far more
serious side of the spectrum of thyroid disease.
• Very high mortality 1:3
• Undiagnosed Hypothyroidism
or usually Untreated. Often linked to a precipitant, such as
acute infection, myocardial infarction, congestive heart failure,
cerebral vascular accident, trauma, or drug toxicity
• Typical patient: elderly female with longstanding hypothyroidism,
• Previous thyroid surgery, History of hypothyroidism,
Levothyroxine replacement, thyroid cancer, surgery, RAI

18. Myxedema Coma: Decompansated
Hypothyroidsm

19. Myxedema Coma: Decompansated
Hypothyroidsm
• Mortality rate in myxedema coma has historically
been as high as 80%
• disease appears more often in white and Hispanic
populations
• greater in females than males (female-to-male
ratio 5-10:1
• The incidence of primary hypothyroidism
increases progressively with age, typically at 40-
50 years. After age 60 years, the prevalence of
hypothyroidism may be as high as 8-10% in
women.

20. History and Symptoms
• Typical Stigmata: dry skin, delayed reflex relaxation, generalized weakness,
edema. Alterations- mental status.
• Lethargy
• Brittle or thinning hair, Dry Hair
• Menstrual irregularity
• Menorrhagia
• Forgetfulness
• Deep, husky voice secondary to mucopolysaccharide infiltration of the vocal cords
• Cold intolerance
• Weight gain
• Muscle/joint pain or weakness
• Inability to concentrate
• Headaches
• Constipation
• Emotional lability
• Depression
• Blurred vision

21. History and Symptoms

22. Causes Of Hypothyroidsm
Worldwide : Iodine Deficiency
Usa : Hashimoto Thyroiditis & Iatrogenic Secondary to treatment of Graves
Disease i.e. surgical or radioactive iodine ablation of the thyroid gland

23. Causes Of Hypothyroidsm
Worldwide : Iodine Deficiency
Usa : Hashimoto Thyroiditis & Iatrogenic Secondary to treatment of Graves
Disease i.e. surgical or radioactive iodine ablation of the thyroid gland
Primary causes : 90-95 %
autoimmune, idiopathic, postoperative, and
congenital etiologies; radiation; radioiodine
therapy; iodine deficiency; metabolic
disorders; and medications (eg, lithium,
amiodarone, phenytoin, carbamazepine,
iodides). Furthermore, those with underlying
autoimmune thyroiditis are susceptible to
disease progression while taking these
medications.

24. Causes Of Hypothyroidsm
Worldwide : Iodine Deficiency
Usa : Hashimoto Thyroiditis & Iatrogenic Secondary to treatment of Graves
Disease i.e. surgical or radioactive iodine ablation of the thyroid gland
Primary causes : 90-95 %
autoimmune, idiopathic, postoperative,
and congenital etiologies; radiation;
radioiodine therapy; iodine deficiency;
metabolic disorders; and medications
(lithium, amiodarone, phenytoin,
carbamazepine, iodides).
Secondary causes
pituitary and hypothalamic disorders such
as trauma, neoplasm, irradiation, and
infiltrative diseases including sarcoidosis
or amyloidosis

25. Precipitating Factors for Myxedema
Coma
• Not Taking Medication or Untreated
• Burns.
• CO2 retention .
• Gastrointestinal hemorrhage .
• Hypoglycemia.
• Hypothermia .
• Infection (Pneumonia, Influenza, UTI/urosepsis , Sepsis ).
• Medications (Amiodarone , Anesthesia, Barbiturates Beta
blockers, Diuretics, Lithium, Narcotics, Phenothiazines,
Phenytoin , Rifampin , Tranquilizers).
• Stroke.
• Surgery.
• Trauma.

26. Workup
• Basic lab tests and radiology
• FT4, TSH
• CBC (anemia), electrolytes
(hyponatremic),Hypoglycemia
• renal function (increased Cr)
• EKG (bradycardia), CXR (effusions)
• Evaluate for pituitary disorders & Coexisting
autoimmune disorders
• Cortisol, cosyntropin stimulation test
• FSH, LH
• ABG: Hypoventilation commonly results in hypercapnia and
hypoxia in patients with myxedema coma
• Blood / Urinary Cultures

27. Thyroid Studies
• Thyroid function studies may not be immediately
available to assist in clinical decision making in the ED.
• Thyroid-stimulating hormone (TSH) is elevated in
primary hypothyroidism, but it may be normal or low in
secondary causes of hypothyroidism.
• Free thyroxine (T4) levels are low.
• Triiodothyronine (T3) resin uptake is decreased.
• Free T4 index (T3 resin uptake x total serum T4) is low.
• Critically ill patients may develop euthyroid sick
syndrome, which must not be confused with a primary
thyroid abnormality. These patients have low to
normal TSH and T4 levels with low T3 levels.

28. Imaging
• Head CT scan (noncontrast) In patients with altered mental status, the scan
may be helpful in ruling out other etiologies such as intracerebral
hemorrhage.
• Echocardiography: Perform this study if pericardial effusion is suspected
• Chest radiography : Cardiomegaly, Effusions

29. Treatment
• ICU admission may be required for ventilatory support and IV
medications
• Parenteral thyroxine
– Loading dose of 300 – 400 μg
– Then 50 μg daily
• Electrolytes
– Water restriction for hyponatremia
– Avoid fluid overload
• Avoid sedation
• Hypothermia, Regular Blankets
• Glucocorticoids
– Controversial but necessary in hypopituitarism or multiple
endocrine failure
– Dose: Hydrocortisone 40 – 100 mg 6 hly for 1 week, then taper

30. Treatment
• Typical levothyroxine dose estimate
1.6 mcg/kg/day
• iv levothyroxine is about 2X more potent than
• oral levothyroxine once stable
• T3 usually not needed
• Endocrinologist Should be Consulted.
• Mortality lowered From 70% to 15-30%.

31. Pearls
• Medication metabolism can be affected
• Hypothyroidism induced ileus causing poor absorption
• Decreased metabolism and clearance (eg sedatives, opiates)
• Replacement of thyroid hormone can precipitate angina or MI
in at-risk patients
• Thyroid hormone treatment may unmask underlying adrenal
insufficiency
• Consider pregnancy test if reproductive age
• May affect anticoagulation – must monitor
• Be careful of euthyroid sick syndrome
• Young, active patients can tolerate sever hypothyroid
symptoms for a long time
• Myxedema can be seen in both hyper and hypothyroidism

32. Thank You