SUN-543 Life-threatening Undiagnosed Myxedema Coma with Initial Clinical Presentation of Septic Shock in an Elderly Patient

Abstract A. Ishtiaq: None. K. Ayla: None. V. Kankani: None. Q. Shi: None. Title: Life-threatening Undiagnosed Myxedema Coma with Initial Clinical Presentation of Septic Shock in an Elderly Patient Introduction: Myxedema coma is considered an extreme complication of hypothyroidism and presents with markedly elevated TSH and low free-T4 in the setting of hypothermia, altered mental status, and associated with multiple organ failure1. If untreated, the mortality rate can be as high as 25-60%. It is estimated that the incidence of myxedema coma is 0.22 per 1,000,000 in the western world and can be an initial presentation of any form of hypothyroidism. Females are 4-5 folds more likely to have myxedema coma compared to males. Moreover, it is more common among the elderly population. Here we present a case of an elderly patient who initially presented with septic shock and was found to have a myxedema coma. Case Description: A 92-year-old female presented to the emergency room from a nursing home with the chief compliant of unresponsiveness. Physical examination: she was lethargic, temperature was 32.4 oC, heart rate: 43/minute, blood pressure: 83/51 mmHg, laboratory test: white blood count &It WBC >: 2.08 &It 4.00-10.80 K/ul >, hemoglobin 7.2 (12-15.3 g/dl), and platelet 81 (140-400 k/ul), Urine analysis showed WBC 20-29 (0-2/HPF), Respiratory pathogen panel: positive for Rhinovirus/Enterovirus. Chest x-ray revealed mild pulmonary vascular congestion. CT of head, chest, abdomen, and pelvis was unremarkable. The patient received 3L normal saline bolus and broad-spectrum antibiotics as per sepsis protocol and atropine. The thyroid panel was ordered about six hours after admission, revealing TSH >100 (0.24-4.2 uIU/ml), and T4<0.1 (0.9-1.7 ng/dl). The patient was given IV hydrocortisone 100 mg followed by weight-based dose of IV levothyroxine. However, despite these interventions, the patient’s condition failed to improve, and a code blue was called. At this time, discussion with family revealed patient’s wishes to not be resuscitated or intubated. Code blue was cancelled, and the patient expired on hospital day two. Discussion: Myxedema coma is a medical emergency that requires aggressive management and correction of any underlying precipitating factors. In our case, life-threatening undiagnosed myxedema coma was as initial clinical presentation of septic shock combined with viral infection of rhinovirus/enterovirus in an elderly patient, which caused it in significant high mortality, it is difficult to say if timely diagnosis and treatment of myxedema coma would have resulted in a better outcome. Sepsis is a common precipitating factor for myxedema coma and should be rapidly treated to avoid progression to fatal outcomes in this severely morbid condition. Reference: 1.William Lai, DO, et al SAT505 Pericardial Effusion as The Primary Manifestation of Hypothyroidism. J Endocr Soc. 2023 Oct 5; 7(Suppl 1), Published online 2023 Oct 5. doi: 10.1210/jendso/bvad114.1977 Sunday, June 2, 2024