Severe hypothyroidism approaching myxedema coma: A case report

Severe hypothyroidism is not a presentation that is encountered daily in the hospital setting. Patients' major complaints are generally seen in common diseases or significant past medical history. Active symptoms of myxedema coma may resemble symptoms of chronic medical conditions in exacerbation and may therefore be very challenging to differentiate at first sight. Early recognition of severe hypothyroidism leading to myxedema coma is crucial so that intensive treatment can be initiated upon suspecting a diagnosis, even before receiving lab findings to support it. We report this rare case of a 57-year-old male with a history of hypothyroidism treated with levothyroxine, who was admitted for congestive heart failure (CHF) exacerbation and severe sepsis due to a complicated urinary tract infection (UTI). On admission, the patient presented with leukopenia and moderate to severe anasarca with pulmonary edema on computed tomography (CT) imaging. Antibiotics and goal-directed medical therapy were reinitiated, except for beta blockers and ACE inhibitors in the setting of hypotension and bradycardia. Subsequently, the patient also presented with clinical symptoms and labs that led us to the diagnosis of severe hypothyroidism approaching myxedema coma. He was experiencing hemodynamic instability after attempting resuscitation protocol, which led us to consult the intensive care unit (ICU) for critical supportive measures. The patient was started on intravenous levothyroxine therapy and hydrocortisone. This treatment approach yielded positive outcomes, as evidenced by improvement in both vital signs and clinical symptoms. This case demonstrates clinical presentation and risk factors that may coincide with other diseases or comorbidities, which could delay the essential treatment of rare diseases like myxedema coma.