endocrine investigation of a case of adrenal insufficiency
TRANSCRIPT
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