Psychotic Disorder as the First Manifestation of Addison Disease: A Case Report

INTRODUCTION

Addison disease is a relatively uncommon endocrine disease resulting from adrenal insufficiency. Psychiatric symptoms are among its rare primary and particularly isolated clinical symptoms. This report presents a case with adrenal insufficiency manifested by the psychotic syndrome.

CASE PRESENTATION

A 28-year-old Iranian female with a history of immune thrombocytopenic purpura (ITP) and asthma since childhood presented with a 13-month history of progressive depression with insomnia and nightmare symptoms. After being prescribed haloperidol, clomipramine, and clonazepam for eight months, abdominal pain and weight loss due to anorexia started. Her physical examination showed skin hyperpigmentation in the elbow, knee, ankle, and buccal mucosa. Physical examination and initial laboratory tests suggested adrenal insufficiency. Addison disease was confirmed according to the laboratory tests and abdominal CT. The symptoms were significantly improved using intravenous hydrocortisone treatment. The patient remained calm and had a normal sleep without depressive symptoms or psychosis after 72 hours of treatment. During one year of follow-up, the patient was in good general condition without psychological symptoms.

CONCLUSIONS

This report shows that psychotic disorder can be the first manifestation of Addison disease. Therefore, physicians should be informed about the neuropsychiatric symptoms of adrenal insufficiency, especially when the patient lacks a family or personal history of psychiatric illness.

[Schmidt’s syndrome: a difficult diagnosis in the Latin American context]

BACKGROUND

Schmidt’s syndrome, also known as poliglandular autoimmune syndrome type 2, is a rare disease that has a prevalence between 1.5-4.5 cases per 100 000 inhabitants. The diagnosis consists in the concomitant presentation of Addison disease, autoimmune thyroid disease and other autoimmune endocrinological conditions. The aim of this paper is to describe a case of Schmidt’s syndrome in the peruvian context and to analyze the difficulties in the diagnosis.

CLINICAL CASE

We present the case of a 43-year-old woman that presents to the emergency room with headache, nausea, vomits and a “syncope episode”. The patient had a history of secondary amenorrhea, Addison disease, hypothyroidism, osteoporosis and diabetes mellitus type 2. Physical exam showed hyperpigmentation, hypotension and bradycardia. Lab exams demonstrated leukocytosis, hyponatremia, hyperglycemia, and compensated metabolic alkalosis. The emergency management consisted on rehydration, corticoids and insulin. During the hospital stance, exams included follicle stimulation hormone increasement and vaginal echography determined uterine hypoplasia. The patient was discharged one month later with Schmidt’s syndrome, based on autoimmune thyroiditis, Addison’s disease and hypergonadotrophic hypogonadism. In a two week later control, the patient was asymptomatic with levothyroxine, fluodrocortisone, estradiol and insulin treatment.

CONCLUSIONS

In our context, Schmidt’s syndrome is a very rare disease, which leads to a late diagnosis and difficult management.

Extended exome sequencing identifies BACH2 as a novel major risk locus for Addison's disease

BACKGROUND

Autoimmune disease is one of the leading causes of morbidity and mortality worldwide. In Addison's disease, the adrenal glands are targeted by destructive autoimmunity. Despite being the most common cause of primary adrenal failure, little is known about its aetiology.

METHODS

To understand the genetic background of Addison's disease, we utilized the extensively characterized patients of the Swedish Addison Registry. We developed an extended exome capture array comprising a selected set of 1853 genes and their potential regulatory elements, for the purpose of sequencing 479 patients with Addison's disease and 1394 controls.

RESULTS

We identified BACH2 (rs62408233-A, OR = 2.01 (1.71-2.37), P = 1.66 × 10^-15 , MAF 0.46/0.29 in cases/controls) as a novel gene associated with Addison's disease development. We also confirmed the previously known associations with the HLA complex.

CONCLUSION

Whilst BACH2 has been previously reported to associate with organ-specific autoimmune diseases co-inherited with Addison's disease, we have identified BACH2 as a major risk locus in Addison's disease, independent of concomitant autoimmune diseases. Our results may enable future research towards preventive disease treatment.