Myxedema coma is a rare, often fatal endocrine emergency that concerns elderly patients
with long-standing primary hypothyroidism; myxedema coma of central origin is exceedingly
rare. Here, we report a 37-year-old woman in whom classical symptoms of hypothyroidism
had been absent. Six years earlier, she had severe obstetric hemorrage and, shortly
after, two subsequent episodes of pericardial effusion. On the day of admission, pericardiocentesis
was performed for the third episode of pericardial effusion. Because of the subsequent
grave arrhythmias and unconsciousness, she was transferred to our ICU. Prior to the
endocrine consultation, a silent myocardial infarction had been suspected, based on
the extremely high serum levels of creatine kinase (CK) and isoenzyme CK-MB. However,
based on thyroid sonography, pituitary computed tomography, elevated titers of antithyroid
antibodies and pituitary stimulation tests, the final diagnosis was myxedema coma
of dual origin: an atrophic variant of Hashimoto's thyroiditis and post-necrotic pituitary
atrophy (Sheehan syndrome). Substitutive therapy caused a prompt clinical amelioration
and normalization of CK levels. Our patient is the first case of myxedema coma of
double etiology, and illustrates how its presentation deviates markedly from the one
endocrinologists and physicians at ICU are prepared to encounter. In addition, cardiac
problems as those of our patient should not discourage from substitutive treatment
(using L-thyroxine and the gastrointestinal route of absorption), if the age is relatively
low.
Key words
Primary Hypothyroidism - Secondary Hypothyroidism - Hashimoto's Thyroiditis - Pericardial
Effusion - Sheehan Syndrome
