Category: Pituitary Disorders/Neuroendocrinology
Objective : not to miss life threatning diagnosis such as Adrenal insuffeciency in presence of hypertension
Methods : case report :
54 year old gentleman with history of treated pulmonary TB came to Emergency with abdominal pain, loss of appetite, weight loss, but no fever, slowness and sever fatigability (unable to walk) for two months.
On examination: drowsy but fully oriented, puffy face, sever skin dryness and deep voice and loss of hair.
BP: 175/92 HR: 67 T: 36.6 C RR: 18 Sugar: 2.0 mmol/l
No goiter nor lymadenopathy, dull heart sounds, basal crackles, soft abdomen.
CNS: intact vision and carnial nerves, but has proximal muscle weakness and delayed tendon reflexes.
Clinically not in myxedema crisis but sever hypothyroidism.
Investigations : Hb 88 MCV 82 PLT 353, Na 121 K 4.5 Creatinine 65 Urea 3.5, Osmolarity Calculated 255 L (275–295), FT4 0.6 L (12.0-22.0 pmol/L), TSH 0.303 (0.270-4.200 uIU/mL), short Synacthen 250mcg cortisol 419 nmol/L (normal > 500), Low gonads and Testosteron.
Enhanced MRI showed small pituitary only.
Started with IV hydrocortisone and oral levothyroxine without IVF, blood pressure managed with amlodipine.
Na start rising daily by 4 mmol/L, patient start feeling better and being awake and taking orally well.
Went home in a good health walking using a stick and instructed about risk of stopping hormonal therapy.
To aware physician about rolling out adrenal insufficiency even in presence of hypertension if clinically suspected in pituitary disease and life threating endocrine emergency.
Results : 54 y/o gentelaman diagnosed with Central Adrenal Insuffeciency in presence of hypertension
Discussion : hyperttension will not roll out adrenal insuffeciency
Conclusion : adrenal insuffeciency is a life threatning diagnosis not to be missed
Prince Sultan Military Medical City, Riyadh, Saudi Arabia, Ar Riyad, Saudi Arabia
Consultant Endocrine & Diabetes