Metwalley and Farghaly Journal of Medical Case Reports 2012, 6:221 http://www.jmedicalcasereports.com/content/6/1/221 for which his insulin dose was decreased to 0.3U/kg. He had lost 2.5kg of weight and developed a craving for salt. He suffered from fatigue and dizziness. He was born and resided in a small village in Upper Egypt to unrelated Egyptian parents. He was the sixth child in his family with no history of diabetes or other auto immune dis- eases among family members. He had frequent hospital admissions for control of blood sugar. He was born at term with a birth weight of 3550 grams. Apart from post circumcision bleeding that was done at the age of two years by a barber, there was nothing significant in his past medical history. On physical examination, his body temperature was 36.1C, pulse rate was 92/min, blood pressure was 80/45mmHg, his height was in the 10th percentile while his weight was in the 25th percentile. He had no pallor, jaundice, or hyperpigmentation of ei- ther the skin or mucous membranes. His thyroid gland was not enlarged either on inspection or palpation. He was prepubertal: pubic and axillary hair Tanner stage 1 and testicular volume 3ml. He had slight abdominal dis- tension, his liver and spleen were not enlarged and there was no evidence of ascities. Skin examination revealed vitiligo in the form of multiple hypopigmented areas located over the chest and abdomen. Serum biochemis- try on admission showed an average blood glucose level of 77mg/dL (normal range: 82 to 110mg/dL), hemoglobin A1c 7.5% (normal range: 3.0 to 6.1), potas- sium: 5.9mmol/L (normal range 3.5 to 5), sodium 121mmol/L (normal range: 130 to 145) and calcium 9.7mg/dL (normal range: 8 to 10.5). Levels of blood urea nitrogen and creatinine were within the normal range. Liver function tests revealed bilirubin 11umol/L (nor- mal <20umol/L), alanine aminotransferase (ALT) 186IU/L (normal <50IU/L), aspartate aminotransferase (AST) 123IUL (normal <50IU/L), alkaline phosphatase 108IU/L, (normal <350IU/L), and albumin 38g/L (nor- mal range: 35 to 45g/L). Complete blood count, serum folate and vitamin B12 levels were normal. Viral hepa- titis screens (HAV IgM, HBsAg, HBsIgM and IgG, Epstein-Barr virus, cytomegalovirus and herpes simplex virus) were negative. Anti-HCV and hepatitis C virus– polymerase chain reaction (HCV–PCR) were positive, with a viral load of 88,440IU/mL. Anti-endomysial antibodies were not detected. There were no sero- logical features of autoimmune hepatitis (anti-smooth muscle antibody, antinuclear antibody, anti-liver/kidney microsomal antibody, and anti-parietal cell antibody were negative), anti-adrenal antibodies were positive and serum immunoglobulins were normal. Hormonal assays revealed cortisol <1.0ug/dL (normal range: 6 to 24), adrenocorticotropic hormone (ACTH) > 1250pg/mL (normal range: 20 to 100), a peak cortisol level below 0.2mcg/dL after intravenous ACTH stimulation test (250mcg). Thyroid stimulating hormone (TSH) was Page 2 of 4 6.11uIU/mL (normal range: 0.4 to 5.0). Anti-thyroglobulin (Tg autoantibodies) were 217.8IU/mL (normal: <120), anti-thyroid peroxidase (TPO autoantibodies) 5176IU/mL (normal 60), and free thyroxine 1.4ng/dL (normal range: 0.7 to 2.0). The serum luteinizing hormone was 0.1mIU/ml (normal range: 2.9 to 21.7), follicle-stimu- lating hormone 0.2mIU/ml (normal range: 5 to 30), testosterone 0.02ng/mL (normal range: 9.0 to 40.0), prolactin 13ng/mL (normal range: 3 to 30). Insulin C- peptide was <0.50ng/mL (normal range: 1.5 to 3.5). Parathormone (PTH) was 33.4pg/mL (normal range: 2 to 72). Thyroid ultrasonography revealed heteroge- neous echogenicity without any nodules, while ultra- sonography of the abdomen was normal. His immunogenetic study demonstrated that human leuko- cyte antigen (HLA) typing was HLA-DR3. Based on combinations of 1DM, subclinical hypothyroidism due to Hashimoto’s thyroiditis, adrenal insufficiency, vilil- ligo and HLA-DR3, a diagnosis of APS2 was made. The presence of positivity for both anti-HCV and HCV-RNA with elevated ALT and AST levels even in the absence of hepatomegaly confirmed the diagnosis of chronic hepatitis C infection. His general condition improved gradually following the administration of hydrocortisone (10mg twice daily) and fludrocortisone (0.1mg twice daily). His diabetes was controlled with intensive multiple daily insulin injections. He was re- ferred to the regional hepatology unit for further as- sessment including liver biopsy and consideration of hepatitis C eradication therapy but his father preferred to delay the treatment because he was worried about the side effects of the treatment. Discussion The association between Addison’s disease and other endocrinopathies was probably first described in 1886. In 1926, Schmidt presented two cases of Addison’s dis- ease with cortical atrophy and lymphocytic infiltration of the adrenal, as well as lymphoid infiltration in the thy- roid [4]. APS2 is rare, because it necessarily requires the presence of Addison’s disease. Considering that the prevalence of idiopathic Addison’s disease has been sus- pected to be 30 to 60 cases/million inhabitants and that about 50% to 75% of Addisonian patients may be affected by thyroid autoimmune disease and insulin dependent diabetes or both, it may be estimated that APS2 occurs in 15 to 45 cases per million inhabitants in the general population. The syndrome may occur at all ages and in both sexes but is most commonly found in middle-aged women. Inheritance is consistent with auto- somal dominance with incomplete penetrance. These patients have an increased frequency of the HLA A1, B8 and DR3 haplotypes [5]. An unexpected fall in insulin requirement in patients with T1DM may be the earliest