Myxedema coma - Revision history

Danbot: Strip excess bold

2026-03-22T09:28:15Z

Strip excess bold

← Revisión anterior		Revisión del 09:28 22 mar 2026
Línea 1:		Línea 1:
	==Background==		==Background==
	*~~'''~~Extreme, decompensated [[hypothyroidism]]~~'''~~ with end-organ dysfunction		*Extreme, decompensated [[hypothyroidism]] with end-organ dysfunction
	*'''True endocrine emergency''' with mortality '''30-60%''' even with treatment<ref>Ono Y, et al. Clinical characteristics and outcomes of myxedema coma: analysis of a national inpatient database in Japan. ''J Epidemiol''. 2017;27(3):117-122. PMID 28142035</ref>		*'''True endocrine emergency''' with mortality '''30-60%''' even with treatment<ref>Ono Y, et al. Clinical characteristics and outcomes of myxedema coma: analysis of a national inpatient database in Japan. ''J Epidemiol''. 2017;27(3):117-122. PMID 28142035</ref>
	*Misnomer: patients are not always comatose and myxedema is not always present		*Misnomer: patients are not always comatose and myxedema is not always present
	*Most common in ~~'''~~elderly women~~'''~~ with undiagnosed or undertreated hypothyroidism		*Most common in elderly women with undiagnosed or undertreated hypothyroidism
	*Precipitants:		*Precipitants:
	**~~'''~~Infection/[[sepsis]]~~'''~~ (most common trigger)		**Infection/[[sepsis]] (most common trigger)
	**Cold exposure, [[hypothermia]]		**Cold exposure, [[hypothermia]]
	**Medication non-compliance with levothyroxine		**Medication non-compliance with levothyroxine
Línea 15:		Línea 15:
	*'''Classic triad''': altered mental status + hypothermia + precipitating event		*'''Classic triad''': altered mental status + hypothermia + precipitating event
	*'''Altered mental status''': confusion, lethargy, obtundation → '''coma'''		*'''Altered mental status''': confusion, lethargy, obtundation → '''coma'''
	*~~'''~~Hypothermia~~'''~~ (may be severe, <32C; ~~'''~~absence of fever despite infection~~'''~~ is classic)		*Hypothermia (may be severe, <32C; absence of fever despite infection is classic)
	*~~'''~~Bradycardia~~'''~~ and ~~'''~~hypotension~~'''~~ (refractory to vasopressors until thyroid hormone replaced)		*Bradycardia and hypotension (refractory to vasopressors until thyroid hormone replaced)
	*~~'''~~Hypoventilation~~'''~~ with [[hypercapnia]] and [[hypoxia]] (respiratory failure)		*Hypoventilation with [[hypercapnia]] and [[hypoxia]] (respiratory failure)
	*~~'''~~Hyponatremia~~'''~~ (due to decreased free water excretion — [[SIADH]]-like)		*Hyponatremia (due to decreased free water excretion — [[SIADH]]-like)
	*~~'''~~Hypoglycemia~~'''~~ (concurrent [[adrenal insufficiency]] or hepatic dysfunction)		*Hypoglycemia (concurrent [[adrenal insufficiency]] or hepatic dysfunction)
	*~~'''~~Non-pitting edema~~'''~~ (myxedema), periorbital swelling		*Non-pitting edema (myxedema), periorbital swelling
	*Delayed deep tendon reflexes (hung-up reflexes)		*Delayed deep tendon reflexes (hung-up reflexes)
	*Ileus, urinary retention, [[hypothermia]]		*Ileus, urinary retention, [[hypothermia]]
	*~~'''~~Pericardial effusion~~'''~~ (may rarely cause tamponade)		*Pericardial effusion (may rarely cause tamponade)

	==Differential Diagnosis==		==Differential Diagnosis==
Línea 35:		Línea 35:

	==Evaluation==		==Evaluation==
	*~~'''~~TSH~~'''~~: markedly elevated in primary hypothyroidism (most common)		*TSH: markedly elevated in primary hypothyroidism (most common)
	**May be low/normal in central (pituitary/hypothalamic) hypothyroidism		**May be low/normal in central (pituitary/hypothalamic) hypothyroidism
	*~~'''~~Free T4~~'''~~: ~~'''~~very low or undetectable~~'''~~		*Free T4: very low or undetectable
	*~~'''~~Free T3~~'''~~: low (but less reliable)		*Free T3: low (but less reliable)
	*~~'''~~BMP~~'''~~: [[hyponatremia]] (present in ~50%), [[hypoglycemia]]		*BMP: [[hyponatremia]] (present in ~50%), [[hypoglycemia]]
	*~~'''~~CBC~~'''~~: may show anemia, leukopenia		*CBC: may show anemia, leukopenia
	*~~'''~~ABG/VBG~~'''~~: respiratory acidosis, hypercapnia, hypoxemia		*ABG/VBG: respiratory acidosis, hypercapnia, hypoxemia
	*~~'''~~Cortisol level~~'''~~ (~~'''~~before starting steroids~~'''~~) — rule out concurrent adrenal insufficiency		*Cortisol level (before starting steroids) — rule out concurrent adrenal insufficiency
	*~~'''~~Lactate~~'''~~: if concern for sepsis		*Lactate: if concern for sepsis
	*~~'''~~ECG~~'''~~: [[bradycardia]], low voltage, prolonged QT, possible J (Osborn) waves		*ECG: [[bradycardia]], low voltage, prolonged QT, possible J (Osborn) waves
	*~~'''~~CXR~~'''~~: cardiomegaly (pericardial effusion), pleural effusion		*CXR: cardiomegaly (pericardial effusion), pleural effusion
	*~~'''~~Infectious workup~~'''~~: blood/urine cultures, CXR (infection is most common precipitant)		*Infectious workup: blood/urine cultures, CXR (infection is most common precipitant)

	==Management==		==Management==
	===Immediate===		===Immediate===
	*'''Airway management''': intubation for respiratory failure or severe AMS		*'''Airway management''': intubation for respiratory failure or severe AMS
	*~~'''~~Passive rewarming~~'''~~ (avoid active external rewarming which can cause vasodilation and cardiovascular collapse)		*Passive rewarming (avoid active external rewarming which can cause vasodilation and cardiovascular collapse)
	*~~'''~~IV access, cardiac monitoring~~'''~~		*IV access, cardiac monitoring
	*~~'''~~Treat precipitant~~'''~~ (antibiotics for suspected infection, dextrose for hypoglycemia)		*Treat precipitant (antibiotics for suspected infection, dextrose for hypoglycemia)

	===Thyroid Hormone Replacement===		===Thyroid Hormone Replacement===
	*~~'''~~IV levothyroxine (T4)~~'''~~ is the mainstay:		*IV levothyroxine (T4) is the mainstay:
	**~~'''~~Loading dose: 200-400 mcg IV~~'''~~ (or 4 mcg/kg lean body weight)		**Loading dose: 200-400 mcg IV (or 4 mcg/kg lean body weight)
	**Then ~~'''~~50-100 mcg IV daily~~'''~~		**Then 50-100 mcg IV daily
	*~~'''~~IV liothyronine (T3)~~'''~~ may be added for severe cases:		*IV liothyronine (T3) may be added for severe cases:
	**~~'''~~5-20 mcg IV~~'''~~ loading dose, then ~~'''~~2.5-10 mcg IV q8h~~'''~~		**5-20 mcg IV loading dose, then 2.5-10 mcg IV q8h
	**T3 has faster onset of action (~4 hours vs 24 hours for T4)		**T3 has faster onset of action (~4 hours vs 24 hours for T4)
	**Use with caution in elderly / cardiac patients (arrhythmia risk)		**Use with caution in elderly / cardiac patients (arrhythmia risk)
Línea 66:		Línea 66:

	===Stress-Dose Steroids===		===Stress-Dose Steroids===
	*~~'''~~Hydrocortisone 100 mg IV q8h~~'''~~ — give BEFORE or concurrent with thyroid hormone<ref>Jonklaas J, et al. Guidelines for the treatment of hypothyroidism. ''Thyroid''. 2014;24(12):1670-1751. PMID 25266247</ref>		*Hydrocortisone 100 mg IV q8h — give BEFORE or concurrent with thyroid hormone<ref>Jonklaas J, et al. Guidelines for the treatment of hypothyroidism. ''Thyroid''. 2014;24(12):1670-1751. PMID 25266247</ref>
	*Rationale: thyroid hormone replacement increases cortisol metabolism; if concurrent adrenal insufficiency exists, this can precipitate [[adrenal crisis]]		*Rationale: thyroid hormone replacement increases cortisol metabolism; if concurrent adrenal insufficiency exists, this can precipitate [[adrenal crisis]]
	*Discontinue steroids once adrenal insufficiency ruled out		*Discontinue steroids once adrenal insufficiency ruled out

	===Supportive Care===		===Supportive Care===
	*~~'''~~Fluid restriction~~'''~~ if severe [[hyponatremia]] (dilutional)		*Fluid restriction if severe [[hyponatremia]] (dilutional)
	*~~'''~~Avoid hypotonic fluids~~'''~~ (worsens hyponatremia)		*Avoid hypotonic fluids (worsens hyponatremia)
	*Cautious IV NS for hypotension		*Cautious IV NS for hypotension
	*~~'''~~Vasopressors~~'''~~ may be needed but often refractory until thyroid hormone takes effect		*Vasopressors may be needed but often refractory until thyroid hormone takes effect
	*~~'''~~Avoid sedatives and opioids~~'''~~ (impair respiratory drive)		*Avoid sedatives and opioids (impair respiratory drive)
	*Electrolyte correction (hyponatremia, hypoglycemia)		*Electrolyte correction (hyponatremia, hypoglycemia)

	==Disposition==		==Disposition==
	*~~'''~~ICU admission for all patients~~'''~~		*ICU admission for all patients
	*Serial monitoring: TSH, free T4, electrolytes, glucose, cortisol		*Serial monitoring: TSH, free T4, electrolytes, glucose, cortisol
	*Improvement in vital signs expected within ~~'''~~24-48 hours~~'''~~		*Improvement in vital signs expected within 24-48 hours
	*Mental status may take '''days to weeks''' to normalize		*Mental status may take '''days to weeks''' to normalize
	*Long-term oral levothyroxine replacement once stabilized		*Long-term oral levothyroxine replacement once stabilized

Danbot: Major update: IV T4/T3 dosing, stress-dose steroids rationale, precipitants, passive rewarming, avoid sedatives, concurrent adrenal insufficiency workup, references with PMIDs

2026-03-21T19:46:38Z

Major update: IV T4/T3 dosing, stress-dose steroids rationale, precipitants, passive rewarming, avoid sedatives, concurrent adrenal insufficiency workup, references with PMIDs

Show changes

Danbot: Add MedicationDose SMW annotations (levothyroxine, hydrocortisone); dosing verified per ATA guidelines

2026-03-20T16:24:14Z

Add MedicationDose SMW annotations (levothyroxine, hydrocortisone); dosing verified per ATA guidelines

← Revisión anterior		Revisión del 16:24 20 mar 2026
Línea 142:		Línea 142:
	*Admit to ICU		*Admit to ICU


			<div style="display:none">
			<!-- SMW MedicationDose annotations for myxedema coma medications -->
			{{MedicationDose\|drug=Levothyroxine\|dose=100-500 mcg (4 mcg/kg) IV loading, then 75-100 mcg IV daily\|route=IV\|context=Thyroid hormone replacement (T4, 1st line)\|indication=Myxedema coma\|display=Levothyroxine (T4)\|notes=ATA recommends combined T4 + T3 therapy; potentially safer in patients with CAD}}
			{{MedicationDose\|drug=Hydrocortisone\|dose=100 mg IV q8h (stress dose)\|route=IV\|context=Empiric stress-dose steroids\|indication=Myxedema coma\|notes=Give until adrenal insufficiency excluded; thyroid replacement may precipitate adrenal crisis}}
			</div>
	==See Also==		==See Also==
	*[[Hypothyroidism]]		*[[Hypothyroidism]]

Elcatracho: /* Hypothermia */

2022-01-05T11:38:27Z

Hypothermia

← Revisión anterior		Revisión del 11:38 5 ene 2022
Línea 33:		Línea 33:
	[[File:PMC2923795 jkms-25-1394-g001.png\|thumb\|A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman. (A, B) Severe periorbital edema and thinned eyebrow. (C, D) Non-pitting edema and desquamation of the hands and feet.]]		[[File:PMC2923795 jkms-25-1394-g001.png\|thumb\|A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman. (A, B) Severe periorbital edema and thinned eyebrow. (C, D) Non-pitting edema and desquamation of the hands and feet.]]
	===[[Hypothermia]]===		===[[Hypothermia]]===
	*Temperature <35.5°C (95.9°F).		*Temperature <35.5°C (95.9°F).
			*Degree of hypothermia is proportional to mortality<ref>Thiessen, MEW. Thyroid and Adrenal Disorders. In Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 120:p 1557-1571.</ref>

	===Cardiovascular===		===Cardiovascular===
	*[[Bradycardia]]		*[[Bradycardia]]

Ostermayer: /* Hormone Replacement */

2021-03-06T22:30:13Z

Hormone Replacement

← Revisión anterior		Revisión del 22:30 6 mar 2021
Línea 120:		Línea 120:
	**Potentially safer in patients with CAD		**Potentially safer in patients with CAD
	**American Thyroid Association recommends treatment with both T4 and T3<ref>Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec. 24 (12):1670-751.</ref>		**American Thyroid Association recommends treatment with both T4 and T3<ref>Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec. 24 (12):1670-751.</ref>
	*'''T3''' 5-20mcg IV followed by 2.5-10mcg q8hr <ref>Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267409/</ref>		*'''T3''' 5-20mcg IV followed by 2.5-10mcg q8hr <ref>Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267409/</ref><ref>Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350620/</ref>
	**Start with 10mcg if elderly or has CAD		**Start with 10mcg if elderly or has CAD
	**Does not require extrathyroidal conversion		**Does not require extrathyroidal conversion

Ostermayer: /* Hormone Replacement */

2021-03-06T22:29:07Z

Hormone Replacement

← Revisión anterior		Revisión del 22:29 6 mar 2021
Línea 120:		Línea 120:
	**Potentially safer in patients with CAD		**Potentially safer in patients with CAD
	**American Thyroid Association recommends treatment with both T4 and T3<ref>Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec. 24 (12):1670-751.</ref>		**American Thyroid Association recommends treatment with both T4 and T3<ref>Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec. 24 (12):1670-751.</ref>
	*'''T3''' 20mcg IV followed by 2.5-10mcg q8hr		*'''T3''' 5-20mcg IV followed by 2.5-10mcg q8hr <ref>Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267409/</ref>
	**Start with 10mcg if elderly or has CAD		**Start with 10mcg if elderly or has CAD
	**Does not require extrathyroidal conversion		**Does not require extrathyroidal conversion

Hoxbox at 18:40, 2 January 2020

2020-01-02T18:40:01Z

← Revisión anterior		Revisión del 18:40 2 ene 2020
Línea 143:		Línea 143:
	*[[Hypothyroidism]]		*[[Hypothyroidism]]
	*[[Thyroid (Main)]]		*[[Thyroid (Main)]]

			==External Links==
			*[https://emcrit.org/ibcc/myxedema/ IBCC Decompensated Hypothyroidism (“Myxedema Coma”)]

	==References==		==References==

Rossdonaldson1: /* Clinical Features */

2019-12-17T23:02:44Z

Clinical Features

← Revisión anterior		Revisión del 23:02 17 dic 2019
Línea 30:		Línea 30:
	[[File:Myxedema face.png\|thumb\|Man with myxedema or severe hypothyroidism showing an expressionless face, puffiness around the eyes and pallor.]]		[[File:Myxedema face.png\|thumb\|Man with myxedema or severe hypothyroidism showing an expressionless face, puffiness around the eyes and pallor.]]
	[[File:Myxedema standing.png\|thumb\|Additional symptoms include swelling of the arms and legs and ascites.]]		[[File:Myxedema standing.png\|thumb\|Additional symptoms include swelling of the arms and legs and ascites.]]
			[[File:PMC3371544 IJD-57-247-g001.png\|thumb\|Pretibial "woody" (i.e. non-pitting) myxedema]]
	[[File:PMC2923795 jkms-25-1394-g001.png\|thumb\|A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman. (A, B) Severe periorbital edema and thinned eyebrow. (C, D) Non-pitting edema and desquamation of the hands and feet.]]		[[File:PMC2923795 jkms-25-1394-g001.png\|thumb\|A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman. (A, B) Severe periorbital edema and thinned eyebrow. (C, D) Non-pitting edema and desquamation of the hands and feet.]]
	===[[Hypothermia]]===		===[[Hypothermia]]===

Rossdonaldson1: /* Evaluation */

2019-12-17T22:35:20Z

Evaluation

← Revisión anterior		Revisión del 22:35 17 dic 2019
Línea 96:		Línea 96:
	**Ventricular dysrhythmias		**Ventricular dysrhythmias
	*Bedside [[cardiac US]] for [[pericardial effusion]]		*Bedside [[cardiac US]] for [[pericardial effusion]]

			===Diagnosis===
			[[File:thyroid studies.JPG\|px200]]

	==Management==		==Management==

Rossdonaldson1 at 22:31, 17 December 2019

2019-12-17T22:31:58Z

← Revisión anterior		Revisión del 22:31 17 dic 2019
Línea 8:		Línea 8:
	*~50% of cases become evident '''''after''''' admission		*~50% of cases become evident '''''after''''' admission
	*Severe hypothyroidism may be first time presentation of hypothyroid<ref>Nicoloff JT et al. A form of decompensated hypothyroidism. Endocrinol Metab Clin North Am. 1993;22:279–90.</ref>		*Severe hypothyroidism may be first time presentation of hypothyroid<ref>Nicoloff JT et al. A form of decompensated hypothyroidism. Endocrinol Metab Clin North Am. 1993;22:279–90.</ref>

	~~{{Thyroid gen background}}~~

	===Precipitants===		===Precipitants===
Línea 26:		Línea 24:
	*[[Trauma]]		*[[Trauma]]
	*[[PE]]		*[[PE]]

			{{Thyroid gen background}}

	==Clinical Features==		==Clinical Features==

← Revisión anterior		Revisión del 23:02 17 dic 2019
Línea 30:		Línea 30:
	[[File:Myxedema face.png\|thumb\|Man with myxedema or severe hypothyroidism showing an expressionless face, puffiness around the eyes and pallor.]]		[[File:Myxedema face.png\|thumb\|Man with myxedema or severe hypothyroidism showing an expressionless face, puffiness around the eyes and pallor.]]
	[[File:Myxedema standing.png\|thumb\|Additional symptoms include swelling of the arms and legs and ascites.]]		[[File:Myxedema standing.png\|thumb\|Additional symptoms include swelling of the arms and legs and ascites.]]
			[[File:PMC3371544 IJD-57-247-g001.png\|thumb\|Pretibial "woody" (i.e. non-pitting) myxedema]]
	[[File:PMC2923795 jkms-25-1394-g001.png\|thumb\|A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman. (A, B) Severe periorbital edema and thinned eyebrow. (C, D) Non-pitting edema and desquamation of the hands and feet.]]		[[File:PMC2923795 jkms-25-1394-g001.png\|thumb\|A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman. (A, B) Severe periorbital edema and thinned eyebrow. (C, D) Non-pitting edema and desquamation of the hands and feet.]]
	===[[Hypothermia]]===		===[[Hypothermia]]===