A Case of Primary adrenal insufficiency (Addison's disease)

with Autoimmune Hypothyroidism consistent with Autoimmune

Polyendocrine Syndrome type II
Data

23-year-old female

HPI

nausea and vomiting x 1week

Reported 8 months of progressively worsening fatigue.

*Previously very active as a ballet student, but for the past

8
months she stopped participating
in ballet because of lack of energy.
*She was now living with her mother and sleeping or
watching
television most of the day.

1weekPTA: One week prior to admission, she developed nausea

and had several episodes of vomiting which provoked her visit to
the Emergency Department.

Pertinent Positive:
(+) poor appetite for months
(+) weight loss 5 to 10 pounds
(+) poor concentration
(+) dry skin
(+) "darkening"of the skin in several areas.
Pertinent negative
No abdominal pain, diarrhea, fevers, dysuria or headache

Past medical history:

Hypothyroidism diagnosed several months, prescribed

levothyroxine, Armour Thyroid but had stopped taking them a
month prior because "they made her feel ill.
Her only current medication was progesterone to regulate her
menstrual cycle.

Family History:

There was no family history of autoimmune or endocrine

disorders.

Physical Examination:
VS:

blood pressure of 93/50 mmHg

heart rate of 104 beats/min.
significant orthostastic changes.

General Appearance:

thin, nontoxic appearing Caucasian female, no distress

alert, oriented and cooperative

Skin: mild skin hyperpigmentation over the knuckles, elbows and

knees.
Pertinent Negative: The thyroid, abdominal, and neurological
examinations were normal.
Laboratory testing:

Normal complete blood count.

LOW Sodium of 111 mmol/L (normal range 135-145)
potassium 4.5 mmol/L
chloride 78 mmol/L
bicarbonate 23 mmol/L
glucose 85 mg/dL

creatinine 0.7 mg/dL

LOW Serum osmolality at 234 mosm/kg (normal range 275295)
LOW urine osmolality of 162 mosm/kg and LOW urine
sodium less than 20 mmol/L consistent with severe
hypovolemic hyponatremia.

CORTISOL level

Random cortisol level was less than 0.2 g/dL and a

subsequent cortisol level following the administration of 250
mcg of Cosyntropin (Cosynstropin stimulation testing) remained
less than 0.2 g/dL.
ACTH level: The plasma adrenocorticotropic hormone (ACTH)
level was elevated at 882 pg/dL (normal range 5-27)

Antibodies

(+) adrenal antibody testing (antibodies against the enzyme 21hydroxylase)

HIGH 1:40 titer (normal<1:10)

Endocrine testing:

Elevated thyroid-stimulating hormone level of 29.2 IU/mL

(normal 0.3-4.7)
Elevated thyroid peroxidase autoantibody level greater
than 600 IU/ml (normal<20)
Normal Estradiol, follicle-stimulating hormone, luteinizing
hormone, and prolactin levels were all within normal limits.