Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Hypothyroidism Presenting as Recurrent Syncopal Attacks: A Missed Diagnosis

Mohammad Alhamaydeh*, Hassan Awais, Majed Ghaly, Genevieve Everett

Internal Medicine Department, Conemaugh Memorial Medical Center, United States

Abstract: Myxedema coma is a severe hypothyroidism which usually occurs due to long-standing, undiagnosed, or untreated hypothyroidism. Fortunately, Myxedema coma is now a rare presentation of hypothyroidism, likely due to earlier diagnosis as most of physicians are familiar with classic signs and symptoms of hypothyroidism and widespread availability of thyroid-stimulating hormone (TSH) assays. However it might be associated with several cardiac arrhythmias including; sinus bradycardia, ventricular tachycardia, and torsade de pointes. We report a case of a 53 year old female who presented with several episodes of syncope that was associated with intermittent torsade de pointes found to have severe hypothyroidism with complete reversal of her symptoms after she was started on thyroid hormonal replacement.

Keywords: hypothyroidism, torsade de pointes, ventricular arrhythmia, myxedema

Received April 02, 2020; Revised May 04, 2020; Accepted May 11, 2020

Citation: Mohammad Alhamaydeh, Hassan Awais, Majed Ghaly, Genevieve Everett, Hypothyroidism Presenting as Recurrent Syncopal Attacks: A Missed Diagnosis. American Journal of Medical Case Reports, 8 (8). 235-236. January 2020. doi:10.12691/ajmcr-8-8-5

1. Introduction

Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is usually resulted from longstanding, undiagnosed or untreated hypothyroidism. It is considered a medical emergency with a high mortality rate.

We present a clinical case of patient who presented with recurrent syncopal episodes that was associated with intermittent torsade de pointes as earliest manifestation of severe hypothyroidism.

2. Case Presentation

A 53 year old female is known case of hypertension, hyperlipidemia, learning disabilities and impulse control disorder. She presented with several episodes of presyncope and syncope of less than 1 min in duration.

On presentation, she was somnolent and lethargic. Initial vitals were; temperature was 36 Celsius, bradycardia in 40s, and blood pressure 100/50. ECG showed sinus bradycardia with bigeminy and prolonged QTc > 600 (Figure 1). Serum (Na, K, Mg) were 131, 4, 2 respectively. After she was admitted, patient had experienced several episodes of syncope. The cardiac monitor and telemetry strips showed episodes of intermittent episodes of torsade de pointes (TDP).

She was given initially on intravenous magnesium sulfate (MgSo4) and later was started on lidocaine infusion for persistence of episodic intermittent torsade de pointes. She denied chest pain or shortness of breathing therefore we started to think about other possible causes of torsade de pointes beside the cardiac ischemia especially her serial Troponin was negative.

Initial serum TSH was 97 uIU/ml (0.35-4.95), free T4 < 0.4 ng/dl (0.7-1.48), and Serum cortisol was < 1.1 ug/dl (4.2-38.7). She was started on IV hydrocortisone and IV levothyroxine with gradual improvement of her clinical status with normalization of QTc with no more syncope episodes and torsade de pointes (Figure 2).

Figure 1. ECG on presentation in ED (left) & Strip rhythm shows TDP (right)

Figure 2. ECG on Discharge with Normalization of QTc

3. Background

Fortunately, Myxedema coma is now a rare presentation of hypothyroidism, likely due to earlier diagnosis as a result of the widespread availability of thyroid-stimulating hormone (TSH) assays [1].

Most patients of myxedema presented with typical features of severe hypothyroidism, however, elderly patients may have non-specific or atypical symptoms therefore physicians should have a high clinical index of suspicion for this fatal condition especially among patients who presented with unexplained cardiopulmonary failure likes unexplained syncope and ventricular arrhythmias [2].

Untreated hypothyroidism has detrimental effects on almost all organs including the heart. It may be associated with a decrease in cardiac output due to decreased myocardial contractility. It can cause cardiac arrhythmias including conduction abnormalities such as sinus bradycardia, ventricular tachycardia, and torsade de pointes [3].

The possible mechanisms that might be responsible for slowing the cardiac electrical conduction and several types of arrhythmias among the patients with hypothyroidism are decreased expression of several cardiac genes that play important role in the cardiac conducting systems [4], decreased function of several enzymes that are involved in calcium current which affects the action potential duration [5], sympathovagal imbalance that might cause increased inhomogeneity of ventricular recovery times [6] and cardiac unresponsiveness to circulating catecholamines as there number of beta adrenergic receptors as result of low serum T3 [7].

4. Conclusion

Besides to the common triggers of polymorphic ventricular tachycardia, torsade de pointes, like acute myocardial ischemia, electrolytes abnormalities and medication side effects, we would like to highlight the importance to rule out other rare but also life threatening conditions like severe hypothyroidism as possible differential diagnosis among patients presenting with syncope with intermittent torsade de pointe.

References

[1]   | Vanderpump MPJ. The epidemiology of thyroid diseases. In: Braverman LE, Utiger RD, eds. Werner and Ingbar’s The Thyroid: A Fundamental and Clinical Text. 9th edition. Philadelphia: JB Lippincott-Raven, 2005; 398-496.
[2]   | Martinelli J, Martinelli MO, Aramaki FO, et al. Hypothyroidism in the elderly. Alzheimer Dement 2013;9(4Suppl): 878.
[3]   | Schenck JB, Rizvi AA, Lin T. Severe primary hypothyroidism manifesting with torsades de pointes. American Journal of the Medical Sciences. 2006; 331(3):154-156.
[4]   | Sara Danzi and Irwin Klein. Thyroid Hormone-Regulated Cardiac Gene Expression and Cardiovascular Disease Thyroid.Jun 2002. 467-472.
[5]   | D Kim and T W Smith, Effects of thyroid hormone on calcium handling in cultured chick ventricular cells. J Physiol. 1985 Jul; 364: 131-149.
[6]   | Vittorio Cacciatori, Maria Luisa Gemma, Power spectral analysis of heart rate in hypothyroidism. European Journal of Endocrinology 143 327±333.
[7]   | Brewster Jr, WR, Isaacs JP, Osgood PF, King TL. The hemodynamic and metabolic interrelationships in the activity of epinephrine, norepinephrine, and the thyroid hormones. Circulation. 1956; 13: 1.