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Case Study-A Case of Myxedema Coma Presenting as Hypoxemic Periodic Paralysis (A rare presentation)

Diagnosis– Myxedema Coma, Hypokalemic Periodic Paralysis.

Patient name ABC, a 30years old female with no history of any medical illness presented on 01-01-2023 with sudden onset flaccid paralysis of all 4 limbs which one of the spoke ICU which has managed through tele-ICU monitoring by our command center. Once the patient came that the critical care team at the command centre started managing this case. On examination, she had diminished deep tendon reflex and prominent neck muscle weakness. GCS was E3V4M4. The medical team discovered during auscultation that the lungs were clear but the bowel sounds were diminished. Laboratory investigations showed high TSH levels at 198.19 µIU/ml, making the thyroid gland not palpable, and hypokalemia with a serum potassium level of 2.0. The rest of the laboratory parameters were normal.

Chest X-ray was normal and abdominal X-ray was shown of dilated bowel loops indicating ileus. CT abdomen could not be done as the facility was not available in Tier 2 Tier 3 city.

The medical team intubated the patient and put them on mechanical ventilation for airway protection due to worsening muscle weakness. They also placed a Ryle’s tube to decompress the abdomen.

The medical team made the diagnosis of Myxedema coma and hypokalemic periodic paralysis based on clinical and laboratory parameters.

First Line Treatment– The medical team placed a central line and started IV potassium supplementation of 60 meq in 30 ml of NS at a rate of 15 ml/hr, along with magnesium, to correct a total of 100 meq of potassium over the next 24 hours. They also started the patient on oral thyroxine 200 mcg for 3 days, followed by 150 mcg.

Outcome– Potassium and thyroxine supplementation gradually lead to clinical recovery in power and bowel movement. Once the patient’s condition improved, the medical team successfully extubated them and transferred them on January 4th, 2023. This case demonstrates that with limited resources and good coordination between the resident doctor and critical care consultant, patients like this can still be managed effectively in Tier 2 and Tier 3 cities. So, they do not need to shift higher cities for good critical care.