Type I Polyglandular Autoimmune Syndrome Clinical Presentation

  • Author: Saleh A Aldasouqi, MD, FACP, FACE, ECNU; Chief Editor: George T Griffing, MD   more...
 
Updated: Aug 18, 2011
 

History

  • Overview of clinical features
    • The 3 major components of polyglandular autoimmune (PGA) syndrome, type I, are (1) chronic mucocutaneous candidiasis, (2) hypoparathyroidism, and (3) autoimmune adrenal insufficiency.
    • The presence of all 3 components is not required to make a diagnosis; at least 2 components have to be present in an individual. Additional manifestations, including, among others, type 1A diabetes (documented autoimmune etiology), hypogonadism, pernicious anemia, malabsorption, alopecia, and vitiligo, may be present as well.
    • The first manifestation usually occurs in childhood, and the complete evolution of the 3 main diseases takes place within the first 20 years of life. Accompanying diseases continue to appear at least until the fifth decade of life.
    • Candidiasis usually is the first clinical manifestation, most often presenting in people younger than 5 years. Hypoparathyroidism occurs next, usually in people younger than 10 years. Lastly, Addison disease occurs in people younger than 15 years.
    • Overall, the 3 components occur in fairly precise chronological order, and they are present in roughly 40% of cases. As mentioned earlier, however, careful follow-up is mandatory to watch for the more dreadful manifestations, eg, adrenal insufficiency, regardless of the reportedly expected pattern of appearance.
    • The probability that multiple components of the disease will occur depends on how early the symptoms appear.
    • In a case of PGA-I reported by Bhansali and colleagues, no candidiasis was noted in an East Indian boy aged 16 years.[5]
  • Mucocutaneous candidiasis
    • This condition usually occurs earliest and is the most common of the 3 main diseases of PGA-I.
    • Assess any young person with moniliasis for a possible state of T-cell deficiency and PGA-I.
    • Between 50 and 100% of patients with PGA-I develop a recurrent monilial infection. Most of the lesions are limited to the skin (usually < 5% of surface area), nails, and oral and anal mucosa.[13] Esophageal involvement may be complicated by strictures and stenosis.
    • Even though the presence of candidiasis is consistent with a T-cell defect, no increased frequency of other opportunistic infections exists.
    • Because these patients have a normal B-cell response to candidal antigens, they are spared from developing disseminated candidiasis.
  • Hypoparathyroidism[4]
    • This is the first endocrine disease to occur during the course of PGA-I, usually developing after candidiasis and before Addison disease.
    • Antiparathyroid antibodies have been reported in 10-40% of patients with hypoparathyroidism; however, whether these are being confused with mitochondrial autoantibodies is still under debate. The pathologic significance of these antibodies is not clear.
    • Other disease states presenting with neonatal hypocalcemia (DiGeorge syndrome or congenital absence or malformation of the parathyroid) must be differentiated from PGA-I. DiGeorge syndrome results from a congenital defective disorder of the branchial clefts. It manifests as hypoparathyroidism and cutaneous candidiasis; unlike PGA-I, DiGeorge syndrome does not involve the adrenal glands.
    • More than 75% of patients develop hypoparathyroidism, which usually presents in persons younger than 10 years.
    • Clinical features may include, among others, (1) tetanic clinical symptoms, such as carpopedal spasm and paresthesias of the lips, fingers, and feet; (2) seizures; (3) laryngospasm; (4) leg cramps; (5) diffuse mild encephalopathy; (6) cataracts; and (7) papilledema. Electrocardiography may show a prolonged QT interval.
  • Adrenocortical failure (Addison disease)
    • Addison disease typically occurs in people aged 10-30 years (mean, 12-13 y); it usually is the third disease to appear in PGA-I.
    • Mineralocorticoid and glucocorticoid deficiencies usually arise simultaneously, but their onset can be dissociated by up to 3 years.
    • CYP21 appears to be the major autoantigen in isolated Addison disease and Addison disease associated with PGA-II. Autoantibodies to CYP17 and a side-chain cleavage enzyme (CYP11A1) have been associated with Addison disease in PGA-I.
    • Early symptoms include weakness, fatigue, and orthostatic hypotension.
    • Pigmentation usually is increased and may serve as a differentiating point from secondary hypoadrenalism (primary pituitary failure).
    • Anorexia, nausea, vomiting, diarrhea, and cold intolerance often occur.
    • Late symptoms include weight loss, dehydration, hypotension, and a small-sized heart.
  • Less common clinical manifestations
    • Hypergonadotropic hypogonadism
    • Type 1 diabetes mellitus
    • Autoimmune thyroid disease (not including Graves disease)
    • Pernicious anemia
    • Chronic atrophic gastritis
    • Chronic active hepatitis
    • Enamel hypoplasia, which occasionally precedes the onset of hypoparathyroidism
    • Asplenia
    • Keratoconjunctivitis
    • Cholelithiasis
    • Malabsorption
    • Alopecia
    • Vitiligo
    • Interstitial nephritis
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Physical

Physical findings in polyglandular autoimmune (PGA) syndrome, type I, are dependent on the components of the syndrome that are clinically manifested at the time of examination.

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Causes

  • Genetic
    • HLA alleles are not seen in polyglandular autoimmune (PGA) syndrome, type I.
    • The postulated genetic locus is described in Pathophysiology.
  • Environmental
    • Precipitators of autoimmunity exist, but they continue to be elusive.
    • Postulations include the association between congenital rubella infections and type 1 diabetes mellitus or hypoparathyroidism.
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Contributor Information and Disclosures
Author

Saleh A Aldasouqi, MD, FACP, FACE, ECNU  Associate Professor of Medicine, Fellowship Program Associate Director, Department of Medicine, Division of Endocrinology, Michigan State University College of Human Medicine

Saleh A Aldasouqi, MD, FACP, FACE, ECNU is a member of the following medical societies: American Association of Clinical Endocrinologists and American College of Physicians

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; Amylin Grant/research funds Clinical Trial; Novo Nordisk Honoraria Speaking and teaching

Coauthor(s)

Olakunle PA Akinsoto, MD, MB, BCh  Consulting Staff, Family Health Center, Jacksonville Medical Center

Olakunle PA Akinsoto, MD, MB, BCh is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association

Disclosure: Nothing to disclose.

Serge A Jabbour, MD  Associate Professor, Department of Medicine, Division of Endocrinology, Thomas Jefferson University

Serge A Jabbour, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, American Thyroid Association, Endocrine Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Ghassem Pourmotabbed, MD†  Former Associate Professor, Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Tennessee School of Medicine and Health Science Center

Ghassem Pourmotabbed, MD† is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS  Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Nutrition, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Mark Cooper, MBBS, PhD, FRACP  Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgments

I would like to thank Jinie Shirey at the Department of Medicine, College of Human Medicine, Michigan State University, East Lansing for manuscript assistance and preparation, and Laura Smith at the Medical Library, Sparrow Hospital, Lansing, Michigan, for assistance in reference retrieval.

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