PSAT303 Fecal Impaction as a Gastrointestinal Prodrome of Myxedema Coma in an Elderly Woman with Multiple Co-morbidities

Introduction

Fecal impaction is a common occurrence in the elderly, with the most common risk factor being chronic constipation. A common cause of chronic constipation that can be overlooked in the elderly is hypothyroidism. If left untreated, hypothyroidism can have life-threatening manifestations including myxedema coma. In this case report, we describe a rare case of myxedema coma with prodromal fecal impaction.

Case description

An 87-year-old female with a past medical history of colon cancer status post partial colectomy, stroke, and end stage renal failure (ESRD) requiring hemodialysis, presented to the emergency department with extreme rectal pain. She was found to have fecal impaction on abdominal x-ray and was manually disimpacted and discharged home. Five days later, she presented with altered mental status in the setting of a new active herpes zoster infection and possible pneumonia. She was hypothermic (95F) and hypoxic, needing supplemental oxygen (2 L nasal cannula). Her labs showed hyponatremia (133 mg/dL), hypoglycemia (43 mg/dL), an elevated TSH level (100.0 mIU/ml) and decreased free T4 level (0.9 ng/L). Her EKG showed first-degree AV block with low voltage QRS complexes and her chest x-ray demonstrated bilateral pleural effusions. A CT scan of her head did not show hemorrhage or stroke. Given her classic clinical presentation and lab work findings, myxedema coma was diagnosed and the patient was treated with levothyroxine and hydrocortisone, though she was later transitioned to hospice as per her wishes.

Discussion

Chronic constipation is a known etiology of fecal impaction and can be caused by many chronic conditions in the elderly including ESRD, immobility, and hypothyroidism. Fecal impaction is easily identified but the investigation for the etiology is often overlooked. In this case, we argue that patients with an initial presentation of fecal impaction or with severe and unexplained constipation may warrant screening for hypothyroidism as a manageable risk factor for fecal impaction. By doing so, early recognition and treatment of hypothyroidism may prevent potentially fatal patient outcomes such as myxedema coma.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

The Awareness of Negative Pressure Pulmonary Edema in the Medical Intensive Care Unit

Negative pressure pulmonary edema (NPPE) is a noncardiogenic-related rapid onset of bilateral pulmonary edema secondary to various etiologies that lead to upper airway obstruction. Despite the fact that it is more commonly seen in the emergency department (ED), pediatric intensive care unit (PICU), and the postanesthesia care unit (PACU), there is a lower disease prevalence in the medical intensive care unit (MICU) as it sometimes could be overlooked upon. Prompt treatment often leads to favorable clinical outcomes. We detail a 55-year-old lady with a past medical history of nephrolithiasis, obesity, and obstructive sleep apnea presented with right flank pain due to right kidney subcapsular hematoma and left hydronephrosis due to distal ureteral calculus requiring urological intervention. She unfortunately subsequently developed NPPE requiring MICU level of care after reintubation. Successful extubation was achieved two days later as timely recognition of NPPE led to proper treatment. She was downgraded to general medicine service and discharged without complications. 

The effect of linagliptin on glycaemic control and tolerability in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

AIM

Linagliptin is a new dipeptidyl peptidase-4 inhibitor recently approved for use in the USA. The objective of this systematic review and meta-analysis was to assess effect of linagliptin on glycaemic control, biomarkers and incidence of adverse events (AEs) in patients with type 2 diabetes mellitus.

METHODS

Five published and four unpublished randomized, clinical trials were identified from multiple databases. Qualitative assessments and quantitative analyses were performed.

RESULTS

Nine studies included 4246 participants with 53% men, 59.4% Caucasians, 38.7% Asians, and age range 45-69 years. Linagliptin was given as monotherapy (vs. placebo) or combined with metformin (vs. metformin + placebo), sulphonylurea (vs. sulphonylurea + placebo) or pioglitazone (vs. pioglitazone + placebo). Linagliptin 5 mg/day for 12-24 weeks, significantly reduced haemoglobin A1c (HbA1c) (-0.63%, p < 0.00001), fasting plasma glucose (FPG) (-1.01 mmol/l, p < 0.00001) and improved disposition index (DI, product of insulin sensitivity and acute insulin secretion) (p = 0.0001). Linagliptin monotherapy was not more effective than metformin at reducing HbA1c or FPG. Similar proportion of patients in linagliptin and placebo groups reported AEs including upper respiratory tract infections, headaches, nausea, hypertension and back pain.

CONCLUSIONS

Linagliptin was associated with modest but significant reduction in HbA1c and FPG and improved DI after 12-24 weeks. Patients who would probably benefit most are those with HbA1c <9%, already on an active agent, compliant with weight reduction strategies, and can recognize and manage hypoglycaemia, fluid retention and upper respiratory tract infections. Long-term studies are needed to determine durability of response, incidence of microvascular and macrovacular complications, cost-effectiveness and safety.