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Severe multisystem organ dysfunction in an adolescent with simultaneous presentation of Addison’s and Graves’ disease

  • Bethany Graulich , Krystal Irizarry , Craig Orlowski , Carol A. Wittlieb-Weber and David R. Weber ORCID logo EMAIL logo
Published/Copyright: December 15, 2020
Journal of Pediatric Endocrinology and Metabolism
From the journal Journal of Pediatric Endocrinology and Metabolism Volume 34 Issue 3

Abstract

Objectives

To report an unusual case of simultaneous presentation of Addison's and Graves' disease in an adolescent female previously diagnosed with type 1 diabetes (T1D) and Hashimoto's.

Case presentation

A 15-year-old female with T1D and hypothyroidism presented to the emergency department with altered mental state, fever, and left arm weakness for one day. Clinical work-up revealed coexistent new-onset adrenal insufficiency and hyperthyroidism. Her clinical course was complicated by severe, life-threating multisystem organ dysfunction including neurologic deficits, acute kidney injury, and fluid overload. Thyroidectomy was ultimately performed in the setting of persistent signs of adrenal crises and resulted in rapid clinical improvement.

Conclusions

Endocrinopathy should be included in the differential diagnosis of altered mental status. This case additionally illustrates the challenges of managing adrenal insufficiency in the setting of hyperthyroidism and supports the use of thyroidectomy in this situation.

Keywords: autoimmune polyglandular syndrome type 2; adrenal insufficiency; Addison’s Disease; Graves’ disease; thyrotoxicosis
Corresponding author: David R. Weber, MD, MSCE, The Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, 19146, Philadelphia, PA, USA, and Department of Pediatrics, Golisano Children’s Hospital, University of Rochester Medical Center, RochesterNY, USA, E-mail:
KI has moved and now affiliated with AdventHeath (Orlando FL, USA), CWW has moved and is now affiliated with The Children’s Hospital of Philadelphia (Philadelphia PA, USA), DRW has moved and is now affiliated with The Children’s Hospital of Philadelphia (Philadelphia PA, USA)

Funding source: National Institute of Diabetes and Digestive and Kidney Diseases

Award Identifier / Grant number: DK114477

Funding source: Strong Children’s Research Foundation

  1. Research funding: DRW was supported by National Institutes of Health DK114477, BG by the Strong Children’s Research Center at the University of Rochester Medical Center.

  2. Author contributions: All of the authors have accepted responsibility for the entire content of this submitted article and approved submission.

  3. Competing Interests: The funding organizations played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

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Supplementary Material

Biochemical response of thyroid function tests to antithyroid medications. Propylthiouracil was initiated on hospital day 1 at a dose of 50 mg every 8 h, increased to 100 mg every 8 h on hospital day 2, and changed to methimazole 20 mg every 6 h on hospital day 3 due to concern for anaphylaxis. Reference ranges in the University of Rochester lab for triiodothyronine (T3, 80–200 ng/dL) and free thyroxine (Free T4, 0.9–1.7 ng/dL) are shown bounded by dashed and solid lines, respectively.

The online version of this article offers supplementary material (https://doi.org/10.1515/jpem-2020-0438).

Received: 2020-07-22
Accepted: 2020-10-30
Published Online: 2020-12-15
Published in Print: 2021-03-26

© 2020 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Review Article
  3. Inborn errors of immunity and metabolic disorders: current understanding, diagnosis, and treatment approaches
  4. Original Articles
  5. Evaluation of hydration status of children with obesity—a pilot study
  6. Relationship between insulin-like growth factor-1, insulin resistance and metabolic profile with pre-obesity and obesity in children
  7. Evaluation of Hemoglobin A1c before and after initiation of continuous glucose monitoring in children with type 1 diabetes mellitus
  8. Karyotype is associated with timing of ovarian failure in women with Turner syndrome
  9. The role of makorin ring finger protein-3, kisspeptin, and neurokinin B in the physiology of minipuberty
  10. Brain MRIs may be of low value in most children diagnosed with isolated growth hormone deficiency
  11. Significant improvement in bone mineral density in pediatric celiac disease: even at six months with gluten-free diet
  12. Population-based waist circumference reference values in Japanese children (0–6 years): comparisons with Dutch, Swedish and Turkish preschool children
  13. Extended growth charts for Indian children
  14. Rib fractures in infancy, case-series and register case-control study from Sweden
  15. Gonadotropin releasing hormone analogue therapy in girls with idiopathic precocious puberty/early-fast puberty: dynamics in adiposity indices, eating habits and quality of life
  16. Case Reports
  17. Transient benign hyperphosphatasemia due to COVID-19: the first case report
  18. ATP synthase deficiency due to m.8528T>C mutation – a novel cause of severe neonatal hyperammonemia requiring hemodialysis
  19. IgG4-related hypophysitis in adolescence
  20. Graves’ disease in a five-month-old boy with an unusual treatment course
  21. Oral sodium phenylbutyrate for hyperammonemia associated with congenital portosystemic shunt: a case report
  22. Severe multisystem organ dysfunction in an adolescent with simultaneous presentation of Addison’s and Graves’ disease
https://doi.org/10.1515/jpem-2020-0438
Keywords for this article
autoimmune polyglandular syndrome type 2; adrenal insufficiency; Addison’s Disease; Graves’ disease; thyrotoxicosis

Articles in the same Issue

  1. Frontmatter
  2. Review Article
  3. Inborn errors of immunity and metabolic disorders: current understanding, diagnosis, and treatment approaches
  4. Original Articles
  5. Evaluation of hydration status of children with obesity—a pilot study
  6. Relationship between insulin-like growth factor-1, insulin resistance and metabolic profile with pre-obesity and obesity in children
  7. Evaluation of Hemoglobin A1c before and after initiation of continuous glucose monitoring in children with type 1 diabetes mellitus
  8. Karyotype is associated with timing of ovarian failure in women with Turner syndrome
  9. The role of makorin ring finger protein-3, kisspeptin, and neurokinin B in the physiology of minipuberty
  10. Brain MRIs may be of low value in most children diagnosed with isolated growth hormone deficiency
  11. Significant improvement in bone mineral density in pediatric celiac disease: even at six months with gluten-free diet
  12. Population-based waist circumference reference values in Japanese children (0–6 years): comparisons with Dutch, Swedish and Turkish preschool children
  13. Extended growth charts for Indian children
  14. Rib fractures in infancy, case-series and register case-control study from Sweden
  15. Gonadotropin releasing hormone analogue therapy in girls with idiopathic precocious puberty/early-fast puberty: dynamics in adiposity indices, eating habits and quality of life
  16. Case Reports
  17. Transient benign hyperphosphatasemia due to COVID-19: the first case report
  18. ATP synthase deficiency due to m.8528T>C mutation – a novel cause of severe neonatal hyperammonemia requiring hemodialysis
  19. IgG4-related hypophysitis in adolescence
  20. Graves’ disease in a five-month-old boy with an unusual treatment course
  21. Oral sodium phenylbutyrate for hyperammonemia associated with congenital portosystemic shunt: a case report
  22. Severe multisystem organ dysfunction in an adolescent with simultaneous presentation of Addison’s and Graves’ disease
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