Fatigue beyond inflammation in inflammatory rheumatic diseases: a narrative review and treatable-traits framework.

Myxoedema coma is a rare, life-threatening condition characterised by profound hypothyroidism and altered mental status (, ). The physician Gull, in 1874, was the first to describe significant hypothyroidism under the term ‘myxoedema’ due to its characteristic features of swollen skin, with the word coma being added later for severe cases with decompensation. Despite its name, most patients are not comatose and the presentation is that of decompensated profound hypothyroidism. Due to widespread easy access to thyroid function testing, it is very unusual for myxoedema coma to be the first presentation of undiagnosed hypothyroidism. The typical patient is usually an elderly female patient with well-established hypothyroidism (either auto-immune or following definitive treatment for hyperthyroidism), who has poor compliance with levothyroxine with a precipitating event triggering the emergency presentation. Prompt thyroid hormone and glucocorticoid replacement combined with supportive care on a high dependency unit (HDU) or intensive therapy unit (ITU), if appropriate, is key, although mortality may still be as high as 50% (, , , , ). We are aware that many hospitals do not have IV levothyroxine readily available. We recommend that local endocrinology teams liaise with their pharmacology and pharmacy colleagues to ensure availability, given the need for rapid access and its long shelf life.