Endocrine emergency: Myxedematous coma and stroke-like presentation due to steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT)

Hypothyroidism presents with various symptoms, including fatigue, cold intolerance, and xerostomia. Myxedema coma (MC) is an endocrinological emergency requiring early treatment to prevent multiple organ failure and improve survival. Other manifestations include Thyroid Stimulating Hormone Receptor Antibody-Related Encephalopathy Syndrome or Steroid-Responsive Encephalopathy Associated with Autoimmune Thyroiditis (SREAT), which can present with seizures, neuropathy, stroke-like symptoms, aphasia, ataxia, hallucinations, and neuropsychiatric alterations. The objective of this report is to describe a geriatric patient with MC concomitant with SREAT, who survived. We present an 80-year-old female patient admitted to the emergency room with altered alertness, hypotension, and multiple organ failure. After undergoing cholecystectomy for hydrocholecyst and urosepsis, she was diagnosed with myxedema coma. Despite initial treatment, she experienced persistent stroke-like drowsiness. Further investigation revealed SREAT through antibody tests and neuroimaging. Treatment with methylprednisolone boluses and a maintenance prednisone regimen led to clinical improvement, and she was discharged. This case highlights the complications of hypothyroidism, including MC and concomitant SREAT, necessitating immediate treatment and glucocorticoid dose adjustment to prevent complications and death. Clinicians should rule out other causes of encephalopathy and consider SREAT, in MC cases with altered TSH but no neurological improvement, using antithyroid antibodies and MRI. • Myxedema coma (MC) is a critical endocrine emergency. • MC requires immediate treatment to avoid organ failure and enhance survival. • Thyroid Stimulating Hormone Receptor Antibody-Related Encephalopathy Syndrome (SREAT) is a diagnosis of exclusion. • SREAT requires paraclinical tests and MRI for diagnosis. • SREAT benefits from immediate treatment with high steroid and immunosuppressants doses.