Endocrine investigation of a case of adrenal insufficiency

Endocrine investigation of a case of adrenal insufficiency

Patient’s particulars Ø Name XYZ Ø Age Ø Sex Ø Occupation Serving sepoy (SSG) Ø Address Muzaffarabad - Azad Kashmir Ø Admitted to MH Rwp 32 years Male 03 Nov 2007

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

History of presenting complaints Ø Apr 06 Ø Jul 06 - Seconded to UN mission in Liberia 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) Ø Jan 07 - Reported again with aggravated complaints - Transferred to level 3 hospital (Liberia) - Worked up for adrenal insufficiency Ø 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) Ø Apr 07 - Repatriated - Rejoined active service - Continued tab prednisolone Ø Aug 07 - Compliance declined & discontinued treatment

History of presenting complaints (contd) Ø Nov 07 - Reported to MH Rawalpindi with loose stools & vomiting - Darkened complexion - Weight loss 7 kg - Preference for salty foods Ø No history of haemetemesis, melaena, jaundice, heat intolerance, palpitations, fever, haemoptysis, polyphagia or polyuria

History (contd) Ø Ø Ø Past history Family history Personal history Dietary history Drug history Not contributory

General physical examination 2000 2007

General physical examination Ø Pulse Ø Blood pressure 96/min, regular 100/70 mm Hg (supine) 30 mm Hg postural drop (systolic) Ø Temperature 98. 40 F Ø Respiratory rate 18/min Ø Weight 52 kg

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

Systemic examination Ø Central nervous system Ø Cardiovascular system Ø Respiratory system Ø Gastrointestinal system Unremarkable

Provisional diagnosis Adrenal insufficiency

Investigations Blood Counts: Haemoglobin Total leukocyte count Neutrophils Lymphocytes Monocytes Eosinophils MCV Platelets ESR 14. 3 g/d. L 9 6. 0 x 10 /L 55% 38% 3% 4% 82. 3 f. L 9 192 x 10 /L 8 mm fall (end of 1 st hr)

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

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

Investigations (contd) Ø Ø Ø Serum cortisol Plasma ACTH Serum Plasma Serum TSH PTH FSH LH 9. 0 >1000 (5 -25) (8 -79) µg/d. L pg/m. L Within reference range

Short synacthen test Ø Basal serum cortisol 8. 1 µg/d. L (5 -25 µg/d. L) Ø Inj synacthen (synthetic ACTH) 250µg administered I/M Ø Serum cortisol after 30 mins 8. 77 µg/d. L Ø Serum cortisol after 60 mins 9. 19 µg/d. L

Investigations (contd) Ø Autoimmune profile: Anti adrenal antibodies Thyroid microsomal antibodies Antinuclear antibodies Ø Contrast enhanced MRI abdomen Ø HIV serology Negative Small sized adrenal glands with no calcification Negative

Final diagnosis Idiopathic adrenal insufficiency

Management Ø Inj ciprofloxacin 500 mg I/V twice daily Replacement therapy: Ø Tab prednisolone 10 mg (morning) and 5 mg (evening) Ø Tab fludrocortisone 0. 05 mg once daily

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