SESSION TITLE: Disorders of the Pleura Student/Resident Case Report Posters
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: We describe a rare case of myxedema coma with massive pleuro-peritoneal effusions 1 week after admission needing multiple drainage procedures and requiring prolonged ventilatory support. We also discuss how severe hypothyroidism changes ventilator-related pathophysiology.
CASE PRESENTATION: A 55 year old male with past medical history of hypertention and alcohol abuse presented to the emergency room with altered mental status, hypothermia (32.5 °F), hypotension with a systolic blood pressure of 64 mm Hg and bradycardia with a heart rate of 32/min due to high degree atrio-ventricular block. He was found to have a TSH of 104.4 uU/ml (high), and T3 of 47.5 ng/dL (low) and he was diagnosed with myxedema coma. Appropriate management with mechanical ventilation, fluids and vasopressor drugs, stress-doses glucocorticoids, and loading dose of intravenous levothyroxine was initiated and he was thereafter maintained with intravenous levothyroxine. On day 7 of admission, he developed moderate to large bilateral pleural effusions with accompanying collapse of both lower lobes (see image) and large ascites with body-wall edema. Mutliple paracentesis and thoracentesis were performed and a total of around 20 liters of pleuro-peritoneal fluid was removed during his intensive care unit (ICU) stay. Serum ascites albumin gradient was less than 1.1 g/dL, which ruled out portal hypertension. The pleural effusions were transudative in nature. The patient did not exhibit any other signs of acute liver decompensation. After two failed attempts, he was eventually extubated on day 12 of his ICU stay.
DISCUSSION: Myxedematous pleuro-peritoneal effusions are extremely rare (1). They may precede the typical manifestations of the disease, thereby misleading the clinician (2). It is postulated that hypothyroidism causes an increase in capillary permeability which is followed by the escape of protein-rich fluid into the extravascular space, causing effusions. Such effusions need frequent drainage, as in our case, which may delay weaning from the ventilator. In addition, severe hypothyroidism can cause an impaired central ventilatory response to hypercarbia and hypoxemia; a propensity for respiratory alkalosis despite low spontaneous minute ventilation due to low CO2 production; and a severe neuromuscular compromise (3). These mechanims can lead to prolonged mechanical ventilation in such patients.
CONCLUSIONS: While myxedematous pleuro-peritoneal effusions are rare, they can be massive and contribute to prolonged respiratory failure.
Reference #1: Gotyo N, Hiyama M, Adachi J, Watanabe T, Hirata Y. Respiratory failure with myxedema ascites in a patient with idiopathic myxedema. Intern Med. 2010;49(18):1991-6
Reference #2: Sachdev Y, Hall R. Effusions into body cavities in hypothyroidism. Lancet. 1975 Mar 8;1(7906):564-6.
Reference #3: Behnia M, Clay AS, Farber MO. Management of myxedematous respiratory failure: review of ventilation and weaning principles. Am J Med Sci. 2000 Dec;320(6):368-73.
DISCLOSURE: The following authors have nothing to disclose: Shalin Kothari, Dragos Manta
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