Case Report: Myxedema Coma Caused by Immunoglobulin A Vasculitis in a Patient With Severe Hypothyroidism

In fact, the present patient walked in our hospital, complaining of IgA purpura without myxedema coma; yet, she developed myxedema coma within 6 hours. Therefore, clinicians should be aware of dynamic changes in the condition of patients with hypothyroidism. Disturbed consciousness, severe respiratory failure, and heart failure have been reported as the keys to the diagnosis of myxedema coma (17).

• UV represents a spectrum of diseases that differ in severity, ranging from an urticaria with minimal vasculitis to a systemic disease that can lead to serious organ-specific complications.
• We appreciate the opportunity to respond to the comments made by Woywodt et al., regarding our evaluation of the association of thyroid disease and vasculitis 1.
• (D) Chest computed tomography showed atelectasis and mild pulmonary congestion.
• As a result, it was deemed clinically necessary to slowly up-titrate levothyroxine further to 150 µg daily; the rash reoccurred at 88 mcg dosage.
• There were twenty-four patients (13.79%) in the group of AAV patients with normal thyroid function.

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In the same study, among 426 patients followed in their thyroid clinic, a 30% incidence of systemic autoimmune disease was observed 6. Serum FT4 and FT3 levels are denoted by closed triangles and circles, respectively. FT4 levels increased and reached above the normal range following levothyroxine administration after 20th day. The shadows represent the normal ranges of serum free T4 and free T3 levels. We appreciate the opportunity to respond to the comments made by Woywodt et al., regarding our evaluation of synthroid irritability the association of thyroid disease and vasculitis 1.

3. Relationship between Thyroid Hormone and Clinical Parameters in AAV Patients with Renal Injury

Rapid aggravation of the patient’s condition after admission led us to diagnose her with myxedema coma. Myxedema coma is an endocrine emergency with a high fatality rate that necessitates thyroid preparations as soon as possible (2). Nevertheless, because myxedema coma occurs suddenly, it is necessary to grasp the dynamic pathological condition during the course. Furthermore, delays resulting from failure to diagnose or wait for confirmation by blood tests have contributed to the high mortality of this disease (7).

• In our study, we were able to review medical records among 52% of case participants, with the history of thyroid disease (or not) and use of specific reported drugs confirmed in 100% of available records.
• However, whether IgA vasculitis causes deterioration of hypothyroidism into myxedema coma requires further clarification.
• There was a delayed increase in the serum free triiodothyronine level, while the serum free thyroxine level was quickly restored to normal.
• Although the pathogenic mechanism of immunoglobulin A (IgA) vasculitis has yet to be elucidated, it has been suggested that immune complexes deposit mainly on arterial walls and activate the complement system (9).

Vasculitis and anti-thyroid medication

• The best defense against recall bias is the confirmation of information through a separate source.
• All patients with clinical features suggestive of urticarial vasculitis were confirmed by biopsy.
• In addition, compared to AAV patients without thyroid dysfunction, they found that those with thyroid dysfunction were more likely to be women and MPO-ANCA-positive 16,17.
• Increasing understanding of the pathophysiological characteristics of all inflammatory vasculitides should lead to better diagnostic and therapeutic approaches to drug-induced vasculitis.

All authors have read and agreed to the published version of the manuscript. Thyroid hormones have a profound impact on the metabolism, growth, development, and differentiation of tissues throughout the body. Moreover, thyroid hormones modulate various aspects of immune function, including immune cell differentiation, proliferation, and cytokine production. They also influence the balance between different types of immune cells, such as T helper 1 (Th1) and T helper 2 (Th2) cells, which play a crucial role in regulating immune responses 7. In conclusion, Henoch–Schönlein purpura (IgA vasculitis) might be occasionally related to thyrotoxicosis and can be intensified by antithyroid agents. A 68-year-old male with a history of hyperlipidemia, sleep apnea, and hypothyroidism secondary to Hashimoto’s thyroiditis presented with a recurring rash over a period of 12 years.

Allergy, Asthma & Clinical Immunology

Direct immunofluorescence (DIF) antibody localization demonstrated negative immunoreactivity for immunoglobulins IgG, IgA, IgM, and complement C3 on sections of frozen skin. UV was suspected, and the diagnosis was confirmed when treatment with 0.6 mg twice daily dosing of colchicine resulted in a good clinical response and subsequent remission of his rash. We described the first case of myxedema coma triggered by IgAvasculitis.

The clinical features of AAV were compared between patients with and without hypothyroidism (Table 2). Patients with AAV and hypothyroidism had an increased risk of venous thrombosis. ICO, VLM, GDR formulated the study question, EV, MF wrote the manuscript. And W.Y.; writing—review and editing, S.G.; visualization, Y.W.; supervision, S.G.; project administration, S.G.; funding acquisition, P.F.

Case Report: Myxedema Coma Caused by Immunoglobulin A Vasculitis in a Patient With Severe Hypothyroidism

Rapid deterioration of the patient’s condition after admission led to the diagnosis of myxedema coma. LT3 administration should be considered as an alternative treatment for myxedema coma patients requiring concomitant glucocorticoid administration. Beyond this, we cannot ignore the established phenomenon of overlapping syndromes of systemic and organ-specific autoimmune diseases. Among others, Biro et al., in a population of 1517 patients with various autoimmune diseases, found that the prevalence of Hashimoto’s thyroiditis or Grave’s disease was 8.2% 6.

In our study, we were able to review medical records among 52% of case participants, with the history of thyroid disease (or not) and use of specific reported drugs confirmed in 100% of available records. With respect to controls, medical records were not available, but our estimates were similar to well-defined population estimates 7. These statistics give us reasonable confidence that recall was not a major issue in our study. As relevant limitations to our study we must mention the small sample size and retrospective nature. Only this data would, in clinical practice, support the screening of AAbs in UV patients.

After careful and precise consideration, we screened out and excluded two patients with primary hyperthyroidism and 460 patients with a lack of thyroid-related laboratory tests or medical record integrity, and 174 AAV patients were finally included in the study. In this cohort of 174 AAV patients, the mean age was 56.9 ± 16.5 years, 102 patients were females (58.6%), and the mean BVAS score was 16.97 ± 6.22. Table 1 summarized the baseline demographic and clinical characteristics of enrolled patients. Severe and long-term hypothyroidism reduces intracellular triiodothyronine (T3) levels, thus leading to lessened sensitivity to high carbon dioxide and low oxygen concentrations, decreased thermogenesis, diminished cardiac output, and increased fluid retention. Respiratory failure (due to hypoventilation), hypothermia, circulatory failure, and central nervous system dysfunction are considered the major clinical symptoms of myxedema coma. Continuous data with normal distribution were presented as means ± standard deviations (SDs).