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Título

Acute hemorrhagic stroke as a trigger for myxedema coma: a case report

RESUMO

Case presentation: A 66-year-old woman, with a previous medical history of diabetes, hypertension and hypothyroidism, was brought to the emergency department due to loss of consciousness nine hours prior to admission. At the initial evaluation, a left central facial palsy and left hemiplegia were observed, as well as severe hypertension. The initial non-contrast head CT showed an acute bleeding in the right nucleocapsular and frontal regions, with areas of subarachnoid hemorrhage. After initial evaluation and emergency management, including endotracheal intubation and infusion of intravenous vasopressors, the patient was transferred to the intensive care unit. She was maintained under continuous venous infusion of sedatives, with the following need of neuromuscular blocking agents, due to frequent patient-ventilator asynchrony despite optimization of ventilatory parameters. Over the following days, after empiric treatment of ventilator-associated pneumonia was started, she developed bradycardia and hypertension, but the non-contrast head CT showed stability of the initial findings, without worsening of the cerebral edema. The patient, then, developed anasarca, worsening of the ventilation parameters and hypoxemia (P/F ratio of 98). At the occasion, a CT pulmonary angiogram was performed, but showed no signals of pulmonary thromboembolism. The laboratory workup revealed a TSH of 55,90 μUI/mL, FT4 < 0,10 ng/dL and total triiodothyronine (T3) < 26 ng/dL. The patient was, then, started on steroids (hydrocortisone) and levothyroxine, with significant improvement of the ventilatory parameters over the following days, in addition to resolution of the bradycardia.

Discussion: Myxedema coma is a severe and life-threatening endocrine emergency that occurs when physiological adaptations to untreated hypothyroidism are overwhelmed by an acute precipitant. The most common triggers to the condition are hypothermia and infection, while other described precipitants are medications, surgery, GI bleeding and myocardial infarction. Although uncommon, acute hemorrhagic stroke is a possible precipitating event and the condition should be early diagnosed for prompt initial treatment.

Final comments: The case presented demonstrates a rare association of acute hemorrhagic stroke and myxedema coma. Given the severity of the condition, early suspicion should be made for prompt initiation of the treatment.

Palavras Chave

Myxedema coma, hemorrhagic stroke