Myxoedema coma, a rare but life-threatening complication of extreme hypothyroidism, is often precipitated by acute stressors and presents a significant diagnostic challenge when coexisting conditions obscure its identification. We report a case of a 40-year-old male presenting with symptoms including shortness of breath, abnormal behavior, fever, and chronic back pain, later diagnosed with disseminated tuberculosis (TB) with meningoencephalitis. Initial findings included obstructive hydrocephalus, L3/L4 spondylitis, and a complex exudative pleural effusion with elevated ADA levels. Despite anti-TB therapy and dexamethasone, he deteriorated with hypotension, bradycardia, hypothermia, and recurrent hypoglycemia. Thyroid function tests revealed severe hypothyroidism (TSH >48.8 mIU/L, T4 <3.2 pmol/L), confirming myxoedema coma, compounded by adrenal insufficiency. Immediate treatment with intravenous hydrocortisone and thyroxine restored hemodynamic stability, with subsequent normalization of heart rate and temperature. Serial thyroid function tests demonstrated recovery. This case underscores the importance of maintaining a high index of suspicion for myxoedema coma in patients with altered mental status, bradycardia, hypotension, hypothermia, and hypoglycemia, particularly with coexisting TB meningoencephalitis. Early recognition and prompt intervention with stress-dose steroids and thyroxine replacement are critical to improving survival in this rare but critical condition.
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