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Letters to the Editor
A forgotten but important risk factor for severe hyponatremia: myxedema coma
Ayse KargiliI, Faruk Hilmi TurgutII, Feridun KarakurtI, Benan KasapogluIII, Mehmet KanbayII, Ali AkcayII
I Department of Endocrinology, Faculty of Medical School, Fatih University - Ankara, Turkey
II Department of Nephrology, Faculty of Medical School, Fatih University - Ankara, Turkey
III Department of Internal Medicine, Faculty of Medical School, Fatih University - Ankara, Turkey., Tel.: + 90-0312-4829166 or 2126262,
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Hypothyroidism is one of the most prevalent endocrine diseases&#46; It can lead to a variety of clinical situations&#44; including congestive heart failure&#44; ileus&#44; hypothermia&#44; electrolyte disturbances and coma&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> Hyponatremia&#44; on the other hand&#44; is the most common electrolyte abnormality encountered in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> Herein&#44; we report a case of myxedema coma with severe hyponatremia&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE HISTORY</span><p id="para20" class="elsevierStylePara elsevierViewall">A 78-year-old male was admitted to the emergency department for confusion&#46; He had had a cerebrovascular event five years ago and had been using anti-hypertensive medication since then&#46; His medications included acetylsalicylic acid 300 mg&#47;day and lacidipine 4 mg&#47;day&#46; On physical examination&#44; the patient was comatose and had a blood pressure of 90&#47;60 mmHg&#44; heart rate of 52 beats&#47;min&#44; respiratory rate of 18 breaths&#47;min and temperature of 35&#46;5 &#176;C&#46; Systemic examination revealed coarse skin&#44; hypoactive bowel sounds&#44; decreased breath sounds and nonpitting pretibial edema&#46; His laboratory findings were as follows&#58; hemoglobin 11&#46;6 g&#47;dL&#44; WBC 7400&#47;mL&#44; glucose 94 mg&#47;dL&#44; urea 30 mg&#47;dL&#44; creatinine 0&#46;5 mg&#47;dL&#44; calcium 8&#46;4 mg&#47;dL&#44; sodium 106 mmol&#47;L&#44; potassium 4&#46;27 mmol&#47;L&#44; CRP 13&#46;6 mg&#47;L&#44; TSH 61&#46;24 uIU&#47;mL&#44; and T4 &#60;0&#46;3 pmol&#47;L&#46; After the patient was diagnosed with severe hyponatremia&#44; his medications were reevaluated&#59; however&#44; no anti-depressants&#44; diuretics or other medications that can cause hyponatremia were reported&#46; The patient&#8217;s urine osmolarity was 280 mOsm&#47;kg&#44; and the urine sodium level was 96&#46;02 mmol&#47;L&#46; A random cortisol level was detected as 17&#46;6 ug&#47;dL &#40;reference range&#58; 5&#8211;25 ug&#47;dL&#41;&#46; Arterial blood gas testing revealed a hypercarbia with pCO<span class="elsevierStyleInf">2</span> of 66&#46;2 mmHg and pH of 7&#46;33&#46; No signs of an acute cerebrovascular event or cerebral edema were detected in brain computed tomography&#46; Myxedema coma was diagnosed&#44; and L-thyroxine sodium 500 &#956;g was administered once orally and continued at a dose of 100 &#956;g&#47;day by nasogastric tube&#46; Isotonic saline was started at a rate of 100 mL&#47;h&#46; Hyponatremia recovered gradually with isotonic saline infusion and L-thyroxine therapy&#46; On the fifth day of her hospitalization&#44; the control serum sodium level was 134 mmol&#47;L&#59; the patient&#8217;s mental state was markedly improved&#44; and the patient was discharged&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para30" class="elsevierStylePara elsevierViewall">Myxedema coma is an uncommon but potentially lethal condition&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> It usually occurs in older patients with long-standing hypothyroidism&#46; Classic manifestations of hypothyroidism include extreme bradycardia&#44; hypotension and delayed relaxation of deep tendon reflexes&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> Myxedema coma was diagnosed in this case based on clinical and laboratory signs including altered mental status&#44; decreased body temperature&#44; very high TSH and low free T4&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Hyponatremia is frequently observed in hospitalized patients&#46; It needs to be treated effectively&#44; and the rate of correction should be adapted to the clinical situation&#46; In our case&#44; the serum sodium level increased gradually with L-thyroxine therapy and isotonic saline infusion&#46; We believe that the coma was associated with both hyponatremia and hypothyroidism in this patient&#46; Although hypothyroidism is known to be a cause of hyponatremia&#44; Kilpatrick et al&#46; failed to identify a definite association between hypothyroidism and hyponatremia&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;5</a> Moreover&#44; a case of life-threatening hyponatremia due to cessation of L-thyroxine treatment has been reported elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a> Because there was no etiological factor for hyponatremia apart from hypothyroidism in this case&#44; we consider that the hypothyroidism caused this manifestation of hyponatremia&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">The correct management of hyponatremia is extremely critical&#44; not only in preventing complications but also in avoiding harm to the patient&#46; A 4- to 6-mmol&#47;L increase in serum sodium concentration corrects many neurological symptoms in the most seriously ill patients&#46; Nevertheless&#44; overcorrection of hyponatremia increases the risks of iatrogenic brain damage&#46; In a recent review&#44; the suggested therapeutic goals for correction rates are 6&#8211;8 mmol&#47;L in 24 hours&#44; 12&#8211;14 mmol&#47;L in 48 hours&#44; and 14&#8211;16 mmol&#47;L in 72 hours&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a></p><p id="para60" class="elsevierStylePara elsevierViewall">In conclusion&#44; severe hyponatremia can be a life-threatening problem in clinical contexts and should be carefully managed&#46; In light of this case&#44; physicians should include hypothyroidism in the differential diagnosis of every patient with hyponatremia&#46;</p></span></span>"
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos