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Thyroxine Reveals Addison's Disease: A Case Report.

Vasiliki Rengina Tsinopoulou1,2, Savvas Kolanis1, Dimitra Katsarou1,2

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Autoimmune Polyglandular Syndrome Type 2 (APS-2) is rare in adolescents. Levothyroxine treatment for autoimmune thyroiditis can trigger adrenal crisis, necessitating careful screening before therapy.

Keywords:
adrenal crisisautoimmune polyglandular syndromehashimoto’s thyroiditishypothyroidismlevothyroxine

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Area of Science:

  • Endocrinology
  • Autoimmune Diseases
  • Pediatrics

Background:

  • Autoimmune Polyglandular Syndrome Type 2 (APS-2) is a rare endocrine disorder characterized by primary adrenal insufficiency, autoimmune thyroiditis (AIT), and/or type 1 diabetes mellitus (T1DM).
  • Adrenal crisis is a rare but serious adverse event associated with levothyroxine treatment for AIT, potentially due to increased cortisol demand.

Observation:

  • A 13-year-old female presented with symptoms initially suggestive of hyperthyroidism, later developing signs of adrenal insufficiency after initiating levothyroxine therapy for Hashimoto's thyroiditis.
  • Clinical presentation included dehydration, tachycardia, electrolyte imbalance, extremely low cortisol, and very high adrenocorticotropic hormone (ACTH) levels.
  • Diagnosis of APS-2 was confirmed by positive adrenal autoantibodies.

Findings:

  • Levothyroxine therapy in a patient with AIT precipitated an adrenal crisis, highlighting a rare but critical treatment complication.
  • The case underscores the importance of considering increased cortisol demand and clearance post-levothyroxine initiation.

Implications:

  • Physicians must carefully screen for adrenal insufficiency in patients with hypothyroidism and Hashimoto's thyroiditis before starting levothyroxine.
  • Proactive adrenal function assessment is crucial to prevent potentially life-threatening adrenal crises in this patient population.