Endocrine Abstracts

JOINT2583

Introduction: Autoimmune diseases, such as autoimmune thyroiditis or celiac disease are frequently associated with type 1 diabetes. Adrenal insufficiency has been rarely observed but it deserves a timely diagnosis. A latent insufficiency always manifests in situations of stress, such as infection, surgery or trauma and then represents a potentially life-threatening condition.

Case presentation: In October 2024, a 36-year-old patient suffering from type 1 diabetes since the age of 12, was transferred to the Department of Endocrinology from the Department of Surgery for further examination of suspected adrenal insufficiency. The patient’s medical history revealed that he was being treated with insulin glargine U300 and prandial aspart only before lunch with good glycometabolic control according to HbA1c level (HbA1c 6.8%) but he had frequent hypoglycemic episodes in the morning, 2-3 times a week. Two weeks earlier, he had had a surgery and cholecystectomy was done due to Mirrizi’s syndrome. Postoperatively, on the second day, he had ketoacidosis, which was treated in Intensive Care Unit. Due to severe pain and clinical presentation of an acute abdomen, CT scan was performed and five days after the first operation, another surgery, appendectomy, was performed. Postoperatively he presented with general weakness, hypotension, low glycaemia and hyponatremia and hypochloremia. Considering the discoloration of the skin, biochemistry findings and clinical presentation, adrenal insufficiency is suspected so further investigation continues at the Department of Endocrinology. The thyroid and sex hormone status was normal. Adrenal axis evaluation showed normal basal cortisol, unexpected for the postoperative period and very high ACTH levels. Cortisol levels in Synacthen test showed no increase, while adrenal insufficiency was confirmed. Antiadrenal antibodies were positive and serum levels of 21-hydroxylase antibodies were above 10 U/ml. Oral hydrocortisone at 15 mg/day divided in 2 daily doses was started. Due to normal PRA there was no need to start mineralocorticoid therapy. Continuous glycemia monitoring was performed and he was discharged from hospital. Three months later, he reported subjectively better quality of life, TIR above 70% and no nocturnal hypoglycemic arousals. Since there is a possibility of Schmidt syndrome, frequent monitoring of thyroid hormones is necessary.

Conclusions: Type 1 diabetes needs prompt recognition or periodical screening of potentially associated autoimmune conditions. Adrenal insufficiency even though rarely encountered among young patients, may be initially symptomless and characterized by slow progression until it turns into acute adrenal crisis, which represents a potentially life-threatening condition.

Keywords: adrenal insufficiency, type 1 diabetes, Schmidt syndrome.