Endocrine Abstracts

Introduction: Polyglandular autoimmune syndrome-type 2 is defined by the presence of autoimmune primary adrenal insufficiency, autoimmune thyroid disease and/or type 1 diabetes.

Case report: A 35 year old female was referred to our endocrinology department with lethargy, poor sleep, palpitations, dyspnoea and 1 stone weight loss, menses were regular. Past medical history included iron deficiency anaemia, irritable bowel syndrome, and gastro-oesophageal reflux. Her thyroid examination was essentially normal with no goitre or dysthyroid eye disease. There was no palmar or buccal pigmentation, blood pressure was normal with no postural drop. Thyroid function testing revealed hyperthyroidism ft4 33 pmol/l (RR 12-2) TSH < 0.01 (0.27-4.2 miu/l), TPO ab 118 (RR < 34 iu/ml), TSH AB 2.7, thyroid ultrasound demonstrated thyroiditis. In addition a low random cortisol level of 20 nmol/l was noted with a subsequent abnormal short synacthen test with a 30-minute cortisol of 22 nmol/l (RR > 450 nmol/l), a markedly elevated ACTH of 2000 ng/l (RR < 63), along with positive anti-adrenal antibodies, aldosterone was low at 34 pmol/l, supporting the diagnosis of Addison’s disease. T1dm and coeliac antibodies were normal. The patient was initiated on hydrocortisone therapy (15 mg in the morning and 5 mg in the evening), informed of the steroid sick day rules, and provided with a medical alert bracelet, in addition to fludrocortisone 50-100 mg od. She was also commenced on carbimazole 20 mg od with normalisation of thyroid function 4 months later with subsequent downtitration to 5 mg od.

Discussion: The coexistence of Addison’s disease and hyperthyroidism was considered unusual. This case emphasizes the importance of a comprehensive endocrine assessment and investigations in patients presenting with multifaceted symptoms. The onset of these conditions is usually separated by years however the simultaneous onset of Addison’s disease and hyperthyroidism in this context is relatively rare.