The first report of a known 4A syndrome patient with suspected manifestations of COVID-19, what was the final outcome?

The present study was performed on a 24-year-old Iranian man referred to Hospital with suspected symptoms of COVID-19, including fever, weakness, and cough. According to medical history, he had Alacrima, esophageal Achalasia, and adrenal insufficiency from childhood. Based on medical records and clinical examinations, the physician suspected 3A syndrome in the patient and requested further examination for MRI, CXR, and COVID-19 RT-PCR test. The result of the COVID-19 RT-PCR test was negative the next day. The patient’s CXR showed ground-glass opacity (GGO) and pulmonary fibrosis. Based on images and MRI reports, severe posterior cortical atrophy disproportionate to chronological age and bilateral atrophy of the lacrimal gland were reported. After reviewing and summarizing the records, history, examinations, and Paraclinical tests, the patient was identified as a case of 4A syndrome. •Syndrome 4A is characterized in increasing order by manifestations of lack of tears, vomiting, hypoglycemia, and finally, lack of pupil dilation and severe sweating from infancy to youth.•Usually, the first sign of suspicion of a genetic defect in the AAAS gene is the lack of tears that appears since infancy.•It seems that a protected lifestyle and prevention of infection in affected people is the best way to control and adapt to this syndrome.•Due to frequent infections, especially various pneumonias, these people are at high risk of contracting COVID-19, so completing vaccinations and following health protocols are vital and necessary. Keywords 4A syndrome; Addison’s disease; Alacrima; Achalasia; COVID-19.