Elsayed Mohamed, Negm Eman, Gahr Maximilian, Schönfeldt-Lecuona Carlos
Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm.
Department of Psychiatry, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
Ann Med Surg (Lond). 2023 Mar 9;85(3):494-496. doi: 10.1097/MS9.0000000000000235. eCollection 2023 Mar.
Autoimmune polyglandular syndrome type 2 (APS-2) features autoimmune Addison's disease, autoimmune thyroid disease, and/or type 1 diabetes mellitus. Addison's disease is occasionally associated with depressive symptoms, therefore patients with APS-2 might present primarily in a psychiatric clinic. Such atypical primary presentation can possibly lead to delayed and/or inadequate diagnosis and management.
A 57-year-old female patient was referred to our psychiatric clinic from an internal medicine hospital presenting severe depressive symptoms. Upon admission, she complained of sadness, loss of interest (anhedonia) and drive, nausea, and loss of appetite. Physical examination revealed generalized hyperpigmentation. Laboratory investigations revealed hyponatremia, hypocalcemia, macrocytic anemia along with treated hypothyroidism, and partially treated adrenal insufficiency.
A diagnosis of the APS-2 was made. Electroconvulsive therapy (ECT) was mandatory and a complete regression of the affective symptoms was achieved.
Organic workout in psychiatry is essential to detect diseases symptomatically or semiologically related to depression. In our case, hyperpigmentation, hypothyroidism, and adrenal insufficiency linked to depressive symptoms led to APS-2 diagnosis. ECT was challenging due to the avoidance of etomidate by the anesthesiologists, due to adrenal insufficiency. The adjustment of ECTs' energy dosage (to avoid too short and ineffective seizures) and optimization of adrenal and thyroid function was essential to reverse the severe depressive syndrome.
2型自身免疫性多腺体综合征（APS - 2）的特征为自身免疫性艾迪生病、自身免疫性甲状腺疾病和/或1型糖尿病。艾迪生病偶尔会伴有抑郁症状，因此APS - 2患者可能最初就诊于精神科门诊。这种非典型的首发表现可能导致诊断和治疗延迟及/或不足。
一名57岁女性患者从内科医院转诊至我们的精神科门诊，表现出严重的抑郁症状。入院时，她主诉悲伤、兴趣缺乏（快感缺失）和动力缺乏、恶心及食欲减退。体格检查发现全身色素沉着。实验室检查显示低钠血症、低钙血症、大细胞性贫血，同时患有经治疗的甲状腺功能减退症和部分治疗的肾上腺功能不全。
确诊为APS - 2。电休克治疗（ECT）是必要的，且情感症状完全缓解。
在精神病学中进行器质性检查对于发现与抑郁症有症状或体征关联的疾病至关重要。在我们的病例中，与抑郁症状相关的色素沉着、甲状腺功能减退症和肾上腺功能不全导致了APS - 2的诊断。由于肾上腺功能不全，麻醉医生避免使用依托咪酯，这使得ECT具有挑战性。调整ECT的能量剂量（以避免癫痫发作过短且无效）以及优化肾上腺和甲状腺功能对于逆转严重抑郁综合征至关重要。
