A patient of vivax malaria and enteric fever presenting as a case of jaundice with leukaemoid reaction.

BACKGROUND

Autoimmune polyglandular syndrome type II (APS-II) is a rare disorder defined by primary adrenal insufficiency in combination with autoimmune thyroid disease and/or type 1 diabetes mellitus. The dynamic nature of autoimmunity complicates diagnosis and management.

CASE REPORT: A 54-year-old woman presented in 2009 with Addison's disease, confirmed by very low cortisol and markedly elevated adrenocorticotropic hormone, despite negative adrenal antibodies. She remained stable on steroid replacement until 2019, when she developed hypothyroidism with elevated thyroid-stimulating hormone (TSH) and positive thyroglobulin antibodies, consistent with Hashimoto's thyroiditis. In 2023, she experienced new hyperthyroid symptoms with suppressed TSH, elevated free thyroxine, positive thyroid-stimulating immunoglobulin, and ultrasound evidence of diffuse hypervascularity, confirming Graves' disease. Concurrent screening revealed haemoglobin A1c 6.2% and positive GAD65 antibody, consistent with a risk of autoimmune diabetes, although without overt hyperglycaemia.

LEARNING POINTS: Autoimmune polyglandular syndrome type II is progressive and unpredictable New endocrinopathies may develop years or even decades after the initial presentation, requiring lifelong surveillance.Autoimmune thyroid disease can be dynamic Although rare (~1% of cases), transitions from Hashimoto's hypothyroidism to Graves' hyperthyroidism are well documented and should be considered when thyroid function changes unexpectedly.Clinical vigilance is crucial Suppressed thyroid-stimulating hormone in a patient on levothyroxine is not always due to over-replacement; testing for thyroid-stimulating immunoglobulin should be considered to exclude evolving Graves' disease.Adrenal insufficiency must be recognized before thyroid therapy Initiating levothyroxine without adequate glucocorticoid coverage can precipitate adrenal crisis in autoimmune polyglandular syndrome type II.Multidisciplinary care improves outcomes Coordinated management between endocrinology, primary care, and other specialties ensures timely detection and treatment of evolving autoimmune conditions.