Endocrine investigation of a case of adrenal insufficiency

Patient’s particulars

Name XYZ Age 32 years Sex Male Occupation Serving sepoy (SSG) Address Muzaffarabad - Azad

Kashmir Admitted to MH Rwp 03 Nov 2007

Generalized weakness

Darkened complexion

Anorexia

Weight loss

Dizziness

Frequent loose stools Vomiting

5 days

2 years

Presenting complaints

History of presenting complaints

Apr 06 - Seconded to UN mission in Liberia

Jul 06 First presentation: - Weakness, easy fatiguability, vomiting &

loss of appetite - Reported to level 2 hospital (Liberia) - Conservatively managed - Reported several times with similar

complaints

History of presenting complaints (contd)

Jan 07 - Reported again with aggravated complaints - Transferred to level 3 hospital (Liberia) - Worked up for adrenal insufficiency

Mar 07 -Transferred to level 4 hospital (Ghana) for confirmation of the diagnosis - Plasma ACTH assay & MRI abdomen were performed - No medical records available - Advised tab prednisolone for 6 months - Rejoined his unit in Liberia

History of presenting complaints (contd)

Apr 07 - Repatriated

- Rejoined active service - Continued tab prednisolone

Aug 07 - Compliance declined & discontinued treatment

History of presenting complaints (contd)

Nov 07 - Reported to MH Rawalpindi with loose stools & vomiting - Darkened complexion - Weight loss 7 kg - Preference for salty foods

No history of haemetemesis, melaena, jaundice, heat intolerance, palpitations, fever, haemoptysis, polyphagia

or polyuria

Past history Family history Personal history Dietary history Drug history

Not contributory

History (contd)

General physical examination

2000 2007

Pulse 96/min, regular

Blood pressure 100/70mm Hg (supine)

30mm Hg postural drop

(systolic)

Temperature 98.40F

Respiratory rate 18/min

Weight 52 kg

General physical examination

General physical examination (contd)

Pallor Jaundice Dehydatrion JVP Not raised Thyroid Fundi Normal No visual field defects No evidence of proximal myopathy

Absent

Not palpable

Mild

Systemic examination

Central nervous

system

Cardiovascular system

Respiratory system

Gastrointestinal

system

Unremarkable

Provisional diagnosis

Adrenal insufficiency

Blood Counts:

Haemoglobin 14.3 g/dL Total leukocyte count 6.0 x 10 /L Neutrophils 55% Lymphocytes 38% Monocytes 3% Eosinophils 4%

MCV 82.3 fL Platelets 192 x 10 /LESR 8 mm fall (end of

1st hr)

9

Investigations

9

Investigations (contd)

Plasma glucose fasting & post prandial

Serum urea Serum creatinine Serum electrolytes - Na - K - Ca

Within reference range

Normal

+

+

++

Investigations (contd) X-ray chest Sputum for AFB Mantoux test TB serology

USG abdomen X-ray abdomen

Liver function tests Normal

No abnormality noted

Investigations (contd)

Serum cortisol 9.0 (5-25) µg/dL Plasma ACTH >1000 (8-79) pg/mL

Serum TSH Plasma PTH Serum FSH Serum LH

Within reference range

Basal serum cortisol 8.1 µg/dL (5-25 µg/dL)

Inj synacthen (synthetic ACTH) 250µg administered I/M

Serum cortisol after 30 mins 8.77 µg/dL

Serum cortisol after 60 mins 9.19 µg/dL

Short synacthen test

Investigations (contd)

Autoimmune profile: Anti adrenal antibodies Thyroid microsomal antibodies Negative Antinuclear antibodies

Contrast enhanced MRI abdomen Small sized adrenal

glands with no

calcification HIV serology Negative

Final diagnosis

Idiopathic adrenal insufficiency

Inj ciprofloxacin 500mg I/V twice daily

Replacement therapy:

Tab prednisolone 10mg (morning) and 5mg (evening)

Tab fludrocortisone 0.05mg once daily

Management

Follow up

Appetite has improved

Gained 4 kg of weight

No postural variation in blood pressure