Enteric Fever Precipitating Myxedema Crisis
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SCIENTIFIC LETTER
Enteric Fever Precipitating Myxedema Crisis Nisha Toteja 1 & Daisy Khera 1 & Rohit Sasidharan 2 & Bharat Choudhary 3 & Kuldeep Singh 1 Received: 2 December 2019 / Accepted: 31 March 2020 # Dr. K C Chaudhuri Foundation 2020
To the Editor: A 14-y-old boy with an underlying diagnosis of hypothyroidism presented with a history of fever for 2 wk. He had a history of non-compliance to thyroid medications. Examination revealed altered sensorium with a dull affect and characteristic physical stigmata of hypothyroidism. He also had hypothermia (lowest up to 32.7 °C), hypotension and sinus bradycardia. He deteriorated rapidly with shock, poor sensorium and seizures requiring mechanical ventilation and vasopressor support. Seizures were attributed to hyponatremia (serum sodium 118 mEq/L) for which 3% saline was given. Laboratory findings revealed elevated thyroid stimulating hormone: 213 mIU/L (normal 0.3–3.6), low T3: 0.38 pmol/L (normal 3.37–6.45) and low T4: 9.01 pmol/L (normal 10.29–21.88). Complete blood count revealed hemoglobin: 7 g/dl, white blood count: 1.5 × 103/μL and platelets: 45 × 103/μL. Serum biochemistry suggested elevated cholesterol 360 mg/dl, aspartate transaminase 108 U/L, alanine transaminase 375 U/L, urea 48 mg/dl and creatinine 1.5 mg/ dl. His anti-thyroid peroxidase (TPO) and anti-thyroglobulin antibodies were elevated. Hence, myxedema crisis was considered as a possibility and prompt empirical treatment with intravenous hydrocortisone 50 mg every 8 hourly and enteral thyroxine 100 micrograms once a day was instituted. Also, he had blood culture-proven Salmonella typhi infection which was treated with antibiotics. The child recovered with this management and at 3 mo follow up thyroid function tests have also shown steady improvement. Myxedema crisis is a rare endocrine emergency that carries significant mortality even up to 60% [1]. It is the culmination
of a chronically decompensated profoundly hypothyroid state. Clinically, it is characterised by lethargy, myxedematous manifestations, hypothermia, bradycardia, hyponatremia, hypotension and altered sensorium in the form of stupor, delirium, or coma [2]. Known precipitants are cold weather, infections, and certain medications. Evidence suggests that most common infections in adults are pneumonia and urinary tract infections. In children, there have been only 7 reported cases globally. Of these, 4 had documented infections at presentation mostly of viral etiology (Table 1). All 4 cases presented as pneumonia or bronchitis although underlying organism could be identified in only two of these [3, 4]. Our index case is the only reported case of a proven bacterial pathogen as the precipitant of myxedema crisis. There is no clear consensus on the therapeutic aspects of myxedema crisis. Some investigators advocate single-agent as thyroxine whereas others have found dual therapy with both thyronine and thyroxine to be more effective [5]. There is usually an element of adrenal insufficiency in these patients necessitating the co-administra
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