Myxedema coma of both primary and secondary origin, with non-classic presentation and extremely elevated creatine kinase

Myxedema coma is a rare, often fatal endocrine emergency that concerns elde rly patients with long-standing primary hypothyroidism: myxedema coma of ce ntral origin is exceedingly rare. Here, we report a 37-year-old woman in wh om classical symptoms of hypothyroidism had been absent. Six years earlier, she had severe obstetric hemorrage and, shortly after, two subsequent epis odes of pericardial effusion. On the day of admission, pericardiocentesis w as performed for the third episode of pericardial effusion. Because of the subsequent grave arrhythmias and unconsciousness, she was transferred to ou r ICU. Prior to the endocrine consultation, a silent myocardial infarction had been suspected, based on the extremely high serum levels of creatine ki nase (CK) and isoenzyme CK-MB. However, based on thyroid sonography, pituit ary computed tomography, elevated titers of antithyroid antibodies and pitu itary stimulation tests, the final diagnosis was myxedema coma of dual orig in: an atrophic variant of Hashimoto's thyroiditis and post-necrotic pituit ary atrophy (Sheehan syndrome). Substitutive therapy caused a prompt clinic al amelioration and normalization of CK levels. Our patient is the first ca se of myxedema coma of double etiology, and illustrates how its presentatio n deviates markedly from the one endocrinologists and physicians at ICU are prepared to encounter. In addition, cardiac problems as those of our patie nt should not discourage from substitutive treatment (using L-thyroxine and the gastrointestinal route of absorption), if the age is relatively low.