Báo cáo y học: Predictors of outcome in myxoedema coma

Tuyển tập các báo cáo nghiên cứu về y học được đăng trên tạp chí y học Critical Care giúp cho các bạn có thêm kiến thức về ngành y học đề tài: Predictors of outcome in myxoedema coma...
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Báo cáo y học: "Predictors of outcome in myxoedema coma" Available online http://ccforum.com/content/12/1/111CommentaryPredictors of outcome in myxoedema comaJennifer Beynon, Simeen Akhtar and Tara KearneyEndocrinology Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UKCorresponding author: Jennifer Beynon, jenniferarnott@doctors.org.ukPublished: 23 January 2008 Critical Care 2008, 12:111 (doi:10.1186/cc6218)This article is online at http://ccforum.com/content/12/1/111© 2008 BioMed Central LtdSee related research by Dutta et al, http://ccforum.com/content/12/1/R1Abstract Due to the rarity of myxoedema coma, very few randomised controlled trials have been undertaken to look at theMyxoedema coma is a rare and life-threatening illness the outcome treatment and outcome; however, myxoedema coma remainsof which has not been robustly studied in large numbers, partly due an important entity to diagnose. The prevalence of hypo-to its low incidence. Dutta and colleagues have explored outcomepredictors in a developing country where access to thyroid thyroidism is likely to increase with advancements in diag-function tests is more limited than in the Western world. Cardio- nostic tools and the increased practice of offering definitivevascular instability, reduced consciousness, persistent hypo- treatment for hyperthyroidism in the form of radioactive iodinethermia, and sepsis all contributed to a poorer outcome, as has treatment and thyroidectomy. Clinicians need to have a highbeen demonstrated before, but a generic outcome predictor model index of clinical suspicion to make an early diagnosis whenwas shown to be useful in this group of patients. Unfortunately, this myxoedema coma is present. Mortality has fallen from 80% toobservational study was unable to show differences in outcomebased on replacement treatment methods and the mortality 20%-40% in treated individuals partly due to increasedremains at 40%. awareness of physicians, improved diagnostic testing, and advances in intensive care [3]. However, these statistics areMyxoedema coma is a rare endocrine emergency resulting based on developed countries and Dutta and colleaguesfrom decompensation of severe hypothyroidism, as Dutta and raise a pertinent point in highlighting the differences in thecolleagues [1] rightly comment in their recent article. It can developing world, where ready access to laboratory tests isbe the presenting feature of hypothyroidism or occur in not always possible and education for the primary physician,previously diagnosed individuals who either have been who does not have to deal with large numbers of thyroidpartially treated or have been exposed to some form of stress. conditions, remains important.Diagnosis is difficult due to the rarity of the condition and itsinsidious onset but is suggested clinically by the presence of It is evident that these patients need to be treated in analtered mental state, dysthermoregulation, and a precipitating intensive care setting with close monitoring of their cardio-factor such as cold exposure, sepsis, or drugs [2-4]. vascular status. Ventilatory support is often needed becauseBiochemically, serum thyroxine (T4) and triiodothyronine (T3) of decreased level of consciousness, respiratory depressionconcentrations are reduced, with either elevated thyroid- secondary to drugs, underlying pneumonia, or sometimesstimulating hormone (TSH) in primary hypothyroidism or low macroglossia or myxoedema of the larynx resulting in airwayor normal TSH in secondary hypothyroidism. One of the obstruction [3]. Hypothermia, besides conventional treatmentpitfalls in diagnosis is that ‘coma’ is a misnomer as patients with warm blankets and fluids, requires replacement withmay present only with signs of cognitive deterioration, such thyroid hormones to normalise thermoregulation. There isas lethargy, confusion, or disorientation. The other charac- consensus that all patients should be given glucocorticoidsteristic clinical features of severe hypothyroidism are often as these patients may have coexistent adrenal insufficiency;present, including dry skin, sparse hair, a hoarse voice, thyroid hormone replacement may result in increasedperiorbital oedema, non-pitting peripheral oedema, macro- metabolism of cortisol, thereby precipitating adrenal crisis.glossia, and delayed deep tendon reflexes. Biochemically, However, controversy regarding optimal replacement regi-anaemia, hyponatraemia, hypoglycaemia, hypercholesterol- mens persists due to the paucity of large clinical trials [6-10].aemia, and high serum lactate dehydrogenase and ...