Related Self Assessment Question A 65-year-old woman is brought into the ED by her family who states that she has been weak, lethargic, and saying "crazy things" over the last 2 days. Her family also states that her medical history is significant only for a disease of her thyroid. Her BP is 120/90 mm Hg, HR is 51 beats per minute, temperature is 94°F rectally, and her RR is 12 breaths per minute. On examination, the patient is overweight, her skin is dry, and you notice periorbital nonpitting edema. On neurologic examination, the patient does not respond to stimulation. Which of the following is the most likely diagnosis? A. Apathetic thyrotoxicosis B. Myxedema coma C. Graves disease D. Acute stroke E. Schizophrenia EXPLANATION: Myxedema coma is a syndrome that represents extreme hypothyroidism. It is a life-threatening condition that has a mortality of up to 50%.Signs and symptoms of hypothyroidism are usually present including dry skin, delayed deep tendon reflexes, coarse hair, and generalized nonpitting edema. Myxedema coma, however, is better characterized by profound lethargy or coma and hypothermia. Hypothermia is present in approximately 80% of patients. In addition, patients may present with respiratory depression and sinus bradycardia. (a) Apathetic thyrotoxicosis is an atypical presentation of hyperthyroidism seen commonly in the elderly but noted in all ages. Signs and symptoms are few and subtle. Patients usually have multinodular goiter. The diagnosis should be considered in elderly patients with chronic weight loss, proximal muscle weakness, depressed affect, new-onset atrial fibrillation, or congestive heart failure. (c) Graves disease is secondary to autoimmune stimulation of thyrotropin (TSH) receptors leading to elevated levels of thyroid hormones. (d) An acute stroke should not cause periorbital edema and hypothermia. (e) Schizophrenia may be mistakenly diagnosed in patients with thyroid abnormalities. It is not a correct diagnosis in this scenario when the patient is unconscious and hypothermic. The answer is B.
