The Sword of Damocles

If you missed the heart-melting and gut-wrenching portrayal by the talented Dr. Harris of Cicero’s famous story of Damocles and Dionysius II — you truly missed out.

Luckily for you, we have some myxedemic coma pearls we would like to drop as today we reviewed a case of a presumed immmune-checkpoint inhibitor mediated autotoimmune thyroiditis leading to a severely elevated TSH and undetectable T4 in a patient with acute encephalopathy.

Clinical Presentation of Myxedemic Crisis

  • severe hypothyroidism leading to altered level of consciousness, hypothermia and findings of organ slowing
  • can be due to chronic, severe hypothyroidism and/or be precipitated by an acute inciting factor such as , infection, MI, cold exposure and certain medications
  • suspect it in any patient with unexplained ALOC, but particularly in those with some other typical finding of myxedemic crisis such as hypothermia, hyponatremia or bradycardia.


  • IV Levothyroxine 200-400mcg x1 as a loading dose followed by daily doses of 50-100mcg until the patient can tolerate oral medications
  • The use of T3 may be useful (center-dependent)
  • Hydrocortisone 100mg q8hrs until you exclude adrenal insufficiency
  • Supportive measures


If you liked the framework for acute encephalopathy but still wanted a mnemonic, never fear — we’ve always got your back!


Neurologic / Toxic / Metabolic / Infectious / Assorted.

I’ll see myself out 🙂



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