Delayed diagnosis with autoimmune polyglandular syndrome type 2 causing acute adrenal crisis: A case report

Ventricular fibrillation induced by fever in structurally normal hearts

Ventricular fibrillation (VF) is a life-threatening arrhythmia that usually happens in patients with structural heart diseases. However, fever-induced ventricular fibrillation in structurally normal hearts was reported, and the four main diseases associated with these cases were Brugada syndrome, long QT syndrome, idiopathic ventricular fibrillation, and non-cardiovascular diseases. In this review, we analyzed this phenomenon and its clinical characteristics.

End-Stage Renal Disease in a Patient With Schmidt’s Syndrome: A Case Report

Schmidt's syndrome constitutes Addison's disease in conjunction with autoimmune hypothyroidism or type 1 diabetes mellitus. It has misleading symptomology and an unclear order of presentation of symptoms. This often results in missed and late diagnosis. Chronic kidney disease is a rarely reported phenomenon in Schmidt’s syndrome. Multiple factors may have the potential to cause renal failure, such as Addison's disease and/or hypothyroidism, the understanding of which is still evolving. A 45-year-old gentleman who is a known case of Schmidt's syndrome presented to us with fatigue, anorexia, and weight gain. Further evaluation revealed a picture of chronic kidney disease. We would like to alert fellow peers of this potential complication and the importance of screening as well as timely diagnosis.

Atypical Case of Schmidt’s Syndrome in a Young Male

Autoimmune polyendocrine syndrome type 2, also known as Schmidt’s syndrome, is a rare autosomal dominant life-threatening syndrome. It is defined by the presence of Addison’s disease in combination with at least one of the known autoimmune diseases: thyroid autoimmune disease, type 1 diabetes, and hypogonadism. It is more common in middle-aged females and is treatable if diagnosed early. However, in this case, we report Schmidt’s syndrome in a young male without a family history.

A 20-year-old male with a past medical history of hypothyroidism, adrenal insufficiency, and type 1 diabetes presented to the emergency department (ED) feeling lethargic, somnolent, and diaphoretic. Laboratory blood tests showed elevated thyroid-stimulating hormone, hyperkalemia of 6.4 mmol/L, and hyponatremia of 131 mmol/l indicating an Addisonian crisis. The patient had low blood glucose (at home: 60 mg/dL, and at ED: 85 mg/dL), hypotensive blood pressure of approximately 85/55 mmHg, and a peaked T-wave on EKG, which were consistent with the diagnosis of Schmidt’s syndrome.

Based on the laboratory findings and history, the patient was diagnosed with polyendocrine syndrome Type 2 (Schmidt’s syndrome). The patient was treated for adrenal insufficiency first followed by thyroid insufficiency.

Schmidt’s syndrome is a rare disease and difficult to diagnose because the presentation depends on which gland is initially involved. A few cases have been reported in the literature of atypical presentations of Schmidt’s syndrome. Therefore, this case report can contribute to the medical literature on Schmidt’s syndrome, which can help in early diagnosis and improve patient outcomes.

Adrenocortical Crisis Triggered by Levothyroxine in an Unrecognized Autoimmune Polyglandular Syndrome Type-2: A Case Report with Review of the Literature

BACKGROUND

Autoimmune polyglandular syndrometype-2 (APS-2) is an uncommon endocrine disorder of Addison's disease with an autoimmune thyroid disorder and/or type 1 diabetes mellitus. The diagnosis is more challenging when a patient presents with nonspecific neuropsychiatric features with hypothyroidism in the setting of unrecognized Addison's disease.

CASE REPORT

We report a case of subclinical autoimmune hypothyroidism presented with nonspecific neuropsychiatric symptoms precipitated by stress. Despite levothyroxine treatment, her symptoms deteriorated and she was admitted with persistent vomiting and hypovolemic shock. Clinical features and laboratory parameters were suggestive of underlying adrenocortical insufficiency. Preexisting autoimmune hypothyroidism combined with Addison's disease confirmed the diagnosis of unrecognized APS-2. She remarkably improved and her thyroid function tests also normalized with the treatment of corticosteroids only.

REVIEW OF THE LITERATURE

We identified only five published case reports of our title by searching the database. Neufeld and Betterle have reported their data of APS-2 and concluded that a full- blown clinical picture of two or more components of the syndrome is like the tip of the iceberg.

CONCLUSION

The patients of one major component of APS-2 should be screened for other components of the disease to pick up latent cases. Addison's disease should be ruled out in patients of hypothyroidism who are intolerant to levothyroxine.

Hyponatraemia and hyperpigmentation in primary adrenal insufficiency

Hyponatraemia is a common electrolyte disturbance with multiple causes. We present a case of a 49-year-old Caucasian female with cholangiocarcinoma, who had a hyponatraemia which was initially assumed to be based on a syndrome of inappropriate antidiuretic hormone secretion as paraneoplastic phenomenon. At physical examination, hyperpigmentation was seen and multiple episodes with syncope were reported. Subsequent endocrine assessment with a synthetic adrenocorticotropin hormone (ACTH) stimulation test and measurement of ACTH levels revealed primary adrenal insufficiency also known as Morbus Addison. We started hydrocortisone and fludrocortisone replacement therapy, resulting in resolving of symptoms, hyponatraemia and hyperpigmentation.

Case of autoimmune polyglandular syndrome type 2: how we uncovered the diagnosis

A 24-year-old man with no significant medical history presented to the medical clinic with vomiting and giddiness for 2 days, loss of appetite for 1 month and progressive fatigability for the preceding 4 months. On examination, he was found to be hypotensive and was admitted to the hospital for work-up. Considering his abnormal labs and physical findings, he was worked up and was diagnosed with primary adrenal insufficiency. On further work-up for the aetiology of his Addison's disease, he was found to have concurrent autoimmune thyroiditis and vitiligo. A final diagnosis of autoimmune polyglandular syndrome type 2 was made. The patient was started on hormone replacement therapy and reported improvement of symptoms on 3-month follow-up visit.

Polyglandular syndrome type 2 in a Mexican family and its association with human leukocyte antigen

The evaluation of first-degree family members is very important to detect additional cases of polyglandular autoimmune syndrome type 2. The genetic evaluation of human leukocyte antigen (HLA) may be useful in the study of this syndrome. This study is the first report of an HLA study of this syndrome in a Mexican family.