An Intriguing Case Report of Type 2 Autoimmune Polyendocrine Syndrome Post-SARS-CoV-2: Cause or Coincidence?

Abstract

Introduction: SARS-CoV-2, the virus responsible for COVID-19, is primarily associated with respiratory illness but can also affect multiple organ systems, including the endocrine system. Viral entry into endocrine tissues may lead to immune activation and trigger or unmask autoimmune conditions in individuals who are genetically predisposed. Autoimmune Polyendocrine Syndrome type 2 (APS-2), a rare disorder characterized by autoimmune Addison's disease (AAD) and autoimmune thyroid disease (AITD), may represent one such manifestation.

Case presentation: We report the case of a 36-year-old male who developed APS-2 following a mild SARS-CoV-2 infection. Two months post-infection, the patient experienced asthenia, hypotension, gastrointestinal symptoms, and weight loss. Laboratory investigations revealed undetectable morning cortisol, positive 21-hydroxylase and thyroid-peroxidase autoantibodies, elevated ACTH and renin, and subclinical hypothyroidism-consistent with a diagnosis of APS-2 (AAD and Hashimoto's thyroiditis). Treatment with cortisone acetate and fludrocortisone led to clinical improvement. No previous history of autoimmune disease was reported. A review of the literature identified only four similar case reports, with varying timelines between SARS-CoV-2 infection and APS-2 diagnosis, suggesting that the infection may act as a trigger in predisposed individuals.

Conclusion: This case adds to limited evidence suggesting a possible link between SARS-CoV-2 infection and the onset or unmasking of APS-2. While a direct causal role of the virus remains uncertain, SARS-CoV-2 may function as an environmental trigger, accelerating the transition from subclinical to clinical autoimmunity in genetically susceptible patients. This observation supports the need for clinical vigilance in post-COVID-19 patients presenting with nonspecific but suggestive endocrine symptoms.