FRI209 Psychiatric Illness Masking Autoimmune Polyglandular Syndrome In A Middle-aged Woman
Authors: Esper Layal , Ibrahim Amira , Sen Sabyasachi 
Published: October 2023

Abstract
Disclosure: L. Esper: None. A. Ibrahim: None. S. Sen: None.
Introduction: Autoimmune polyglandular syndrome type 2 (APS-2) or Schmidt's syndrome, is a rare disorder characterized by the coexistence of autoimmune adrenal and thyroid disease and/or type 1 diabetes mellitus. Clinical case: A 51-year-old woman with past medical history of depression and bipolar disorder presented to the hospital with weakness and dizziness. The patient reported increased dizziness and weakness over several months that progressed and limited her level of daily activities. She had been experiencing decreased energy, poor appetite and occasional nausea but denied vomiting or abdominal pain. She also denied any changes in her weight. She suffered from constipation but that was her baseline for many years. She was diagnosed with bipolar disorder with depression in her 20s and required multiple admissions for severe depression. She had been following up with her psychiatrist and assumed to have worsening depression. Her mood stabilizers and antidepressant medications were adjusted over several months without improvement. In the Emergency Department, her blood pressure was 98/58. Her heart rate was 57. Labs revealed Na: 115, K: 5.3 and Cr:0.87. The patient was admitted to the general medical floor for treatment of symptomatic hyponatremia. Hyponatremia was initially thought to be due to depression and decreased oral intake. She was started on fluid with slight improvement in sodium levels without significant improvement in symptoms. Further work up for the etiology of her hyponatremia and weakness elicited 2 endocrinopathies. She had a morning cortisol of 4. Cosyntropin stimulation test did not elicit a proper response. At baseline, cortisol was 4.2 and then 4.5 and 4.3 at 30 and 60 minutes, respectively. She was also found to have hypothyroidism (TSH 10, FT4: 0.4). Patient was started on hydrocortisone and fludrocortisone initially and subsequently thyroid hormone replacement was added with resolution of symptoms and hyponatremia. She reported being postmenopausal since age 41. Given that the patient had at least two endocrinopathies, 21 hydroxylase antibody testing was ordered and found to be positive. Addison's disease diagnosis is often delayed. A cross-sectional study in 2013 showed that less than 50% of patients with adrenal insufficiency were correctly diagnosed within the first half year after symptoms appeared. It however took more than 5 years until the condition was diagnosed for 20% patients. (1) The delay was primarily attributed to concomitant presence of psychiatric and gastroenterological conditions. Conclusion: Poly endocrinopathies often present with vague symptoms that need to be worked up to prevent the life-threatening effects of APS2 including adrenal crisis. We present an uncommon case of middle-aged woman with Tri-glandular syndrome with delayed diagnosis due to underlying psychiatric disease.
(1) Meyer et al. Horm Metab 2013; 45:92-95
Presentation: Friday, June 16, 2023