Endocrine investigation of a case of adrenal insufficiency

1. Endocrine investigation of a case of adrenal insufficiency

2. 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

3. 5 days Presenting complaints • Generalized weakness • Darkened complexion • Anorexia • Weight loss • Dizziness • Frequent loose stools • Vomiting 2 years

4. 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

5. 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

6. History of presenting complaints (contd) • Apr 07 -Repatriated - Rejoined active service - Continued tab prednisolone • Aug 07 - Compliance declined & discontinued treatment

7. 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 ofhaemetemesis, melaena, jaundice, heat intolerance, palpitations, fever, haemoptysis, polyphagia or polyuria

8. History(contd) • Past history • Family history • Personal history • Dietary history • Drug history Not contributory

9. 2000 General physical examination 2007

10. General physical examination • Pulse 96/min, regular • Blood pressure 100/70mm Hg (supine) 30mm Hgpostural drop (systolic) • Temperature 98.40F • Respiratory rate 18/min • Weight 52 kg

11. General physical examination (contd) • Pallor • Jaundice • Dehydatrion • JVP Not raised • Thyroid • Fundi Normal • No visual field defects • No evidence of proximal myopathy Absent Mild Not palpable

12. Central nervous system Cardiovascular system Respiratory system Gastrointestinal system Unremarkable Systemic examination

13. Provisional diagnosis Adrenal insufficiency

14. Investigations 9 9 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 /L ESR 8 mm fall (end of 1st hr)

15. Investigations (contd) Normal Within reference range + + ++ • Plasma glucose fasting & post prandial • Serum urea • Serum creatinine • Serum electrolytes - Na - K - Ca

16. Investigations (contd) • X-ray chest • Sputum for AFB • Mantoux test • TB serology • USG abdomen • X-ray abdomen • Liver function tests Normal No abnormality noted

17. Serum cortisol 9.0 (5-25) µg/dL Plasma ACTH >1000(8-79) pg/mL Serum TSH Plasma PTH Serum FSH Serum LH Investigations (contd) Within reference range

18. Short synacthen test • 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

19. 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

20. Final diagnosis Idiopathic adrenal insufficiency

21. Management • Inj ciprofloxacin 500mg I/V twice daily Replacement therapy: • Tab prednisolone 10mg (morning) and 5mg (evening) • Tab fludrocortisone 0.05mg once daily

22. Follow up • Appetite has improved • Gained 4 kg of weight • No postural variation in blood pressure