SHM Converge Scientific Abstract ePoster Gallery-A Man With a Tan

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A 23-year-old previously healthy man presented after two days of worsening fatigue and then non-responsiveness. EMS found severe hypoglycemia (glucose 28). On arrival he was hypotensive, somnolent, and notably hyperpigmented, including buccal mucosa and palmar creases, with a “well-tanned” appearance even in sun-protected areas.<br /><br />Initial evaluation raised concern for sepsis and endocrine failure. He was admitted to the ICU and treated with IV hydrocortisone, fluids, and later thyroid hormone and mineralocorticoid replacement. During the hospital course, he developed profound bradycardia, shortness of breath, and recurrent unresponsiveness, which improved with ionotropic support.<br /><br />Laboratory and imaging findings supported autoimmune polyglandular syndrome type II (APS II) with primary adrenal insufficiency and autoimmune hypothyroidism. Key results included TSH 50, low free T3, strongly positive thyroid peroxidase antibodies, positive intrinsic factor blocking antibodies, and negative diabetes and celiac serologies. CT abdomen/pelvis showed atrophic adrenal glands. Thyroid ultrasound showed a heterogeneous, hypervascular gland without nodules.<br /><br />The discussion emphasized that APS II is a rare autoimmune disorder, typically presenting in adults in their 20s to 40s, and may include adrenal insufficiency, hypothyroidism, type 1 diabetes, celiac disease, pernicious anemia, and autoimmune hypogonadism. The patient’s hypoglycemia and hyperpigmentation were explained by cortisol deficiency and increased POMC production, respectively. A key management point is that steroids must be given before thyroid hormone in patients with both adrenal insufficiency and hypothyroidism to avoid precipitating adrenal crisis.<br /><br />After treatment, the patient improved quickly, resumed normal activities within weeks, and by three-month follow-up his metabolic abnormalities, cytopenias, and skin pigmentation had largely resolved.

Asset Subtitle

Ann Marie Kumfer

Meta Tag

Author List Ann Marie Kumfer, Emma Astrike-Davis

Category Clinical Vignettes

Concept Autoimmune Polyglandular Syndrome Type II

Concept Adrenal Insufficiency

Concept Autoimmune Hypothyroidism

Concept Hypoglycemia

Concept Hydrocortisone

Distinguished Non-Finalist

Presenter Organization University of North Carolina Hospital

Presenting Author Ann Marie Kumfer

Track Adult

Keywords

autoimmune polyglandular syndrome type II

primary adrenal insufficiency

autoimmune hypothyroidism

severe hypoglycemia

hyperpigmentation

Addison disease

thyroid peroxidase antibodies

intrinsic factor blocking antibodies

adrenal crisis

hydrocortisone replacement

Autoimmune Polyglandular Syndrome Type II

Adrenal Insufficiency

Autoimmune Hypothyroidism

Hypoglycemia

Hydrocortisone