Myxoedema coma with pancytopenia and diagnostic challenges

Myxoedema coma is a rare, life-threatening complication of severe hypothyroidism especially in geriatric population. We report a diagnostically challenging case of a 65-year-old man presenting with altered consciousness, bradycardia, anasarca, and hypothermia, consistent with myxoedema coma. Initial management included high-dose enteral thyroxine and IV hydrocortisone, but clinical improvement was minimal. Investigations revealed pancytopenia, deranged liver enzymes, and high anti-TPO antibodies. Severe constipation, meningoencephalitis, hepatic encephalopathy, Addisonian crisis, and other systemic illnesses were considered and excluded. The poor response to oral thyroxine suggested malabsorption, likely due to intestinal mucosal edema. Lack of IV thyroxine availability in a resource-limited setting posed a therapeutic challenge. The patient’s condition deteriorated with cardiac arrest, pleuropericardial effusions, and ventilator-associated pneumonia, ultimately leading to death. This case highlights the atypical presentation, diagnostic dilemmas, and management challenges of myxoedema coma in low-resource environments. Early recognition and aggressive management are crucial to improving outcomes in this often-misdiagnosed endocrine emergency.