Case Presentation: A 20-year-old male with a history of type 1, insulin-dependent diabetes mellitus presented to urgent care for extreme fatigue and weakness. Upon presentation, the patient’s blood pressure was 54/37mmHg and heart rate 133bpm, so he was directed to the emergency department (ED) for evaluation and management due to significant concern with these vitals. In the ED, the patient was given a 2.5L bolus of normal saline which improved his blood pressure to 98/62mmHg. Now stabilized, the patient subjectively reported a 3-to-4-month history of 40-pound weight loss, extreme fatigue, loss of appetite, episodes of lightheadedness, blurry vision, muscles “giving out”, and decreased motivation. The reported symptoms led to the patient quitting his job and sleeping late with low productivity. Once the patient was stabilized and admitted, his clinical workup included infectious disease and endocrine testing. Significant findings included AM cortisol levels less than 0.2 ug/dL, a level signifying adrenal insufficiency without further need for stimulation testing for confirmation. Further lab work showed elevated 8AM ACTH of 1165 pg/mL, signifying primary adrenal insufficiency, elevated TSH at 16.19 mU/L, signifying hypothyroidism, and elevated Hemoglobin A1c of 11.4%, signifying uncontrolled diabetes mellitus. To manage the new diagnosis of primary adrenal insufficiency, the patient was started on both mineralocorticoids and glucocorticoids. Fludrocortisone was prescribed at 0.05mg daily and hydrocortisone was prescribed at 20mg daily split into three doses of 10mg first thing in the morning, 5mg 5 hours later and 5mg in another 5 hours. After steroid replacement was started and blood sugars were controlled with insulin titration, thyroid replacement therapy was started. With the above management, the patient’s vitals remained stable, symptoms improved, instructions were given on new medical treatment including sick day rules for increase in daily steroid replacement, and the patient was discharged from the hospital with scheduled follow-up in the outpatient setting within one week.
Discussion: Schmidt Syndrome, also known as Polyglandular Autoimmune Syndrome Type 2, is an autoimmune disorder of three endocrine diseases: adrenal insufficiency, hypothyroidism, and type 1 diabetes mellitus. It is a rare condition with varying prevalence in research from 1 in 1,000 to 1 in 20,000 people. It is diagnosed in females three times more commonly than males and has a typical onset between the ages of 20 and 40. With the concurrent diagnoses of adrenal insufficiency, hypothyroidism, and type 1 diabetes mellitus, the patient was diagnosed with Schmidt Syndrome. Implications of this syndrome is defining management as completed above with proper steroid replacement before thyroid replacement.
Conclusions: Because of the association between multiple autoimmune endocrine disorders, if a diagnosis of adrenal insufficiency is made, Schmidt Syndrome should be included in the differential diagnosis and further workup of concurrent endocrine disorders should be made to coordinate subsequent treatment and minimize risk of health complications. Steroid replacement must be done before thyroid replacement therapy; otherwise, an increase in thyroid hormone levels can lead to accelerated metabolism of cortisol and cause severe adrenal crisis. Therefore, it is strongly indicated to test for other autoimmune endocrine disorders when adrenal insufficiency is diagnosed in a patient.