Metwalley and Farghaly Journal of Medical Case Reports 2012, 6:221 http://www.jmedicalcasereports.com/content/6/1/221 sign of adrenal failure. Our index case developed recur- rent hypoglycemia attacks without any change in his treatment or physical activity. Hypoglycemic attacks are considered to be caused by enhanced insulin sensitivity secondary to glucocorticoid deficiency [6]. Hashimoto’s thyroiditis was diagnosed in our case on findings of sero- positivity for Tg and TPO autoantibodies, and slightly high TSH accompanied by morphological changes seen on thyroid ultrasound [7]. Symptoms and signs of hypo- thyroidism and hypoadrenalism are often non-specific. Since early diagnosis and treatment of these hormonal insufficiencies are vital, it is essential to always consider an association. Adrenal insufficiency should be consid- ered in patients with autoimmune thyroid disease or T1DM who develop non-specific illness or become ser- iously ill, or in diabetic patients whose insulin require- ments fall inexplicably [8]. The hyperpigmention of the skin and mucous membranes was not obvious in our case. The absence or presence of hyperpigmentation in Addison’s disease is related to the duration of the illness and the time taken to stimulate the pituitary to produce ACTH. Although pigmentation is a very useful sign in Addison’s disease, its absence by no means excludes the diagnosis. It seems that only an awareness of the possi- bility of the disease will lead to an early diagnosis [9]. Our case showed vitiligo over the chest and abdomen which is a chronic disorder that causes patchy hypo- pigmentation of the skin. It occurs when the melano- cytes, which are derived from the neural crest, die or are unable to function. The precise pathogenesis of vitiligo is not yet fully understood but an autoimmune etiology is the most widely accepted. It is mandatory to actively look for, and if necessary, investigate patients with viti- ligo for other autoimmune diseases [10]. In Egypt, HCV infection in diabetic children is considered a health- related infection; with a prevalence of anti-HCV among diabetic children of 3.5%, it may be attributed to repeated hospitalization, insulin injections, shared insu- lin vials and shared spring-triggered devices for capillary blood glucose monitoring [3]. Our case was diagnosed with chronic hepatitis C. We suggest that the risk factors for contraction of hepatitis C in our case were frequent hospital admissions and circumcision by a barber which is a common practice in villages in Upper Egypt. These suggestions are supported by Kalil et al. [11] and Med- hat et al. [12] in their study regarding risk factors of ac- quisition of hepatitis C in children in Upper Egypt. HCV seems to be the virus usually associated with the appear- ance of autoimmune diseases, and the relationship be- tween chronic HCV infection and some autoimmune disease has been studied. For some of these disorders their association with HCV infection is well recognized while for others it remains probable or weak [13]. HCV infection has been associated with Type 2 diabetes Page 3 of 4 mellitus; however, Chen et al. [14] reported T1DM one year after a blood transfusion-related HCV infection. The exact mechanisms underlying HCV-mediated T1DM still are not well understood and several investi- gators have proposed that cross reactive mechanisms are operating in the generation of autoimmunity in HCV in- fection. This hypothesis is supported by the discovery of remarkable amino acid similarities between HCV and glutamic acid decarboxylase 65 (GAD65), protein tyro- sine phosphatase islet cell antigen-2 and phogrin [15]. Identification of the type and extent of autoimmune dis- orders in children with HCV infection is important for the following reasons: First, this awareness can result in rapid diagnosis and treatment of these diseases. Second, the existence of an autoimmune disorder in patients with HCV infection requires clinicians with good experi- ence in the management of such cases. Third, patients presenting with these disorders can be targeted for HCV testing [13]. Our case presents three very interesting and unusual aspects. First, given that APS2 occurs most often in middle-aged women, its presentation in a boy during childhood is uncommon. In this communication, we report the case of a 14-year-old boy with APS2 with HCV infection. Second, the association of APS2 with chronic hepatitis C in our case would suggest adding APS2 to the list of autoimmune diseases apparently associated with chronic hepatitis C. Finally, hepatic dys- function in Egyptian children with APS2 is not necessar- ily due to autoimmune hepatitis but can be attributed to HCV infection. Conclusions As APS2 can be fatal, it is important to maintain a high index of suspicion to enable early diagnosis and start ap- propriate treatment. Egyptian children presenting with autoimmune disorders should be tested for HCV infection. Consent Written informed consent was obtained from the patient’s next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations APS2: Autoimmune polyendocrine syndrome type 2; HCV: Hepatitis C virus; T1DM: Type 1 diabetes mellitus. Competing interests The authors declare that they have no competing interests. Authors’ contributions KAM and HSF diagnosed, investigated, followed-up and managed the patient and drafted the manuscript. Both authors read and approved the final manuscript.