Wiśniewski Oskar Wojciech, Matuszak Paulina, Kasprzak Agnieszka, Łącka Katarzyna
Poznan University of Medical Sciences, Poznan, Poland.
Department of Internal Diseases and Diabetics, Heliodor Swiecicki Clinical Hospital, Poznan, Poland.
Caspian J Intern Med. 2021;12(Suppl 2):S392-S396. doi: 10.22088/cjim.12.0.392.
Schmidt's syndrome (SS) is a rare endocrine disorder (14-20:1000000), which consists of autoimmune thyroiditis (AIT) and autoimmune Addison's disease (aAD), and usually occurs in young adults. Here, we report a unique case of late-onset SS manifesting initially with isolated severe hyponatremia and present the hazardous outcomes of preliminary misdiagnosis.
A 78-year-old female presented to the emergency department with a two-day history of diarrhea, emesis and disturbances in consciousness. She also reported general fatigue and increasing weakness in the last month. Urgent laboratory findings revealed isolated severe hyponatremia (serum sodium=108 mmol/l) and initial treatment with active sodium infusions was started, although with no improvement in the patient's neurological status after 5 days (serum sodium=127 mmol/l). Meanwhile, the patient developed recurring episodes of hypoglycemia and symptoms portending adrenal crisis (blood pressure=105/58 mmHg, heart rate=96 bpm, severe whole-body muscle pain, two loose stools), which required immediate i.e. hydrocortisone treatment. Reduced blood cortisol, elevated adrenocorticotropic hormone (ACTH) and atrophic morphology of the adrenal glands in computed tomography imaging contributed to the final diagnosis of aAD and SS consequently, since the patient had a past medical history of AIT.
Isolated severe hyponatremia should not be underestimated as the first sign of aAD. Appropriate cause-specific treatment is crucial in managing hyponatremia.
施密特综合征（SS）是一种罕见的内分泌疾病（发病率为14 - 20/1000000），由自身免疫性甲状腺炎（AIT）和自身免疫性 Addison 病（aAD）组成，通常发生于年轻人。在此，我们报告一例以孤立性严重低钠血症起病的迟发性 SS 罕见病例，并呈现初步误诊导致的不良后果。
一名78岁女性因腹泻、呕吐及意识障碍两天就诊于急诊科。她还自述近一个月全身乏力且日益虚弱。急诊实验室检查发现孤立性严重低钠血症（血清钠 = 108 mmol/L），遂开始积极补钠治疗，然而5天后患者神经状态并无改善（血清钠 = 127 mmol/L）。同时，患者出现反复低血糖发作及提示肾上腺危象的症状（血压 = 105/58 mmHg，心率 = 96 次/分钟，严重全身肌肉疼痛，两次稀便），这需要立即进行氢化可的松治疗。血液皮质醇降低、促肾上腺皮质激素（ACTH）升高以及计算机断层扫描成像显示肾上腺萎缩形态，最终促成了 aAD 和 SS 的诊断，因为该患者既往有 AIT 病史。
孤立性严重低钠血症作为 aAD 的首发症状不应被低估。针对病因进行恰当治疗对于管理低钠血症至关重要。
