Myxedema Coma

• Decompensated hypothyroidism
• Precipitated by infection, MI, CVA, medications
• Hypothermia, altered mental status
• Hypoglycemia
• Hypotension
• Hyponatremia
• Bradycardia
• Treat with levothyroxine (500 mcg PO or IV) and corticosteroids

Thyroid Storm

• Sx's include unintended weight loss, AFib, dysrhythmias, intractable diarrhea, anxiety, agitation, restlessness
• Low TSH and high free T4

1. Propranolol (control beta adrenergic sx's and block conversion T4 to T3)
   
2. Propylthiouracil or methimazole (reduce TH synthesis and block conversion T4 to T3)
3. Potassium Iodide (reduce TH release, wait at least one hour after the PTU or MMI to administer)
4. Steroids (block conversion T4 to T3)

• Avoid Aspirin (increases T3 and T4)
  

Addison's Disease (Primary Adrenal Insufficency)

• Adrenal insufficency
• Glucocorticoids - cortisol (hydrocortisone)
  
• Mineralocorticoids - aldosterone (fludricortisone)
• Hyperpigmentation
• Excess ACTH release
• Skin creases (palms), oral, nipples
  
• Adrenal Crisis
• Volume Depletion / hypotension
  
• Hypoglycemia
• Hyponatremia
• Hyperkalemia
• Hypercalcemia
• Treatment
• Hydrocortisone (usually 100 mg IV)
• Search for precipitating cause
  
• Caused by
• Auto-immune diseases
• Infections (tuberculosis, HIV, fungal)
  
• Metastatic cancers (lymphoma, lung, breast, colon, stomach)
  
• Waterhouse-Friderichsen syndrome

Secondary (Pituitary - ACTH) / Tertiary (Hypothalamus - CRH) Adrenal Insufficency

• Impairment of the pituitary gland or hypothalamus
• Most commonly from prolonged exogenous steroids
• Pituitary or Hypothalamic tumors
• Sheehan's syndrome

Conn's Syndrome

• Aldosterone-Producing Adenoma
• Results in
• Hypernatremia
• Hypokalemia
• Metabolic alkalosis
  
• Increased H2O uptake
• Treatment
• Spironolactone
  

Aldosterone

• Mineralocorticoid
• Results in
• Hypernatremia
• Hypokalemia
• Metabolic alkalosis
  
• Increased H2O uptake