Addison’s Case Study
A female patient who was 30 years old of admitted in the month of September and claimed to have had persistent vomiting for the past three months five times to fifteen times in a single day. She could not tolerate any oral intake as she was vomiting and nauseated due to dehydration. She had normal bowel motions and had no symptoms of infection and micturition; she, however, had noticed significant weight loss in the past few months. She has been referred directly to a gastroenterologist due to her vomiting that was persistent, thus she well knew about hypothyroidism. She then had to undergo an (OGD) oestrosophaogastroduodenoscopy which then indicated that she had gastritis which further leads to her being introduced to the therapy of the proton pump inhibitor. Her blood test indicated negative tissues of transglutaminase antibodies, gastric parietal cells antibodies are positive and she also had a schedule for CT enterography. Given that this history was obtained, she was treated for gastritis. Her blood pressure was low and her sodium level was 133 mmol/L which indicated that it was secondary to dehydration. The intravenous fluid was used to treat her which got subsequent discharges due to antiemetics (Presotto et al, 2005 ).
Due to a Mallory-Weiss tear, the patient again came with persistent vomiting after 4 months. She then mentioned she was still losing weight from 50kg to 41 kg and with an ongoing lethargy. Her pregnancy test was negative and she also described abdominal pain from her right side. She denied having had forced vomiting and abuse of thyroxine. About her family history, she was not sure about anything. She was had never had alcohol but claimed to be a social smoker. On keen examination, she was hypotensive, very thin and tachycardic. She had pigmentations on her skin and clinically dehydrated.
she had hypopigmentation which is a skin condition for Addison disease as her skin was darker than normal. Observations on her skin indicated that she had nipples, scars, skin folds such as the groin or armpits, she had pressure points like ate the toes knees and her elbows. She had mucous membranes in her gums and cheeks. In addition to her skin condition, she also had hair loss. This is common in women with primary Addison disease as they normally lose their underarm hair and pubic hair. Men with the same disease do not particularly lose their hair since their testes make the androgens that are responsible for the growth of the hair (Cervera et al, 2009).
*Labs & Diagnostic Tests*
Further investigations indicated that her levels of sodium were 128 mmol/L while normal sodium levels should be between 133 to 146 mmol/L. her potassium levels were at 4.9 which is normal since it should be between 3.4 and 5.3 mmol/L. her C reactive proteins were 16 instead of being less than 5. Haemoglobin pigment was 12.4 g/dL instead of 12.5 to16 /dL and her white cell count (WCC) was at 11.6 instead of 4-11*10^9/L adding to mild eosinophilia. After acquiring the history of the patient and her findings, a request for random cortisol was requested and it came back as 2 nmol/L instead of 102 to 535 nmol/L. her renal and liver tests turned out to be normal. Her thyroid-stimulating hormone (TSM) was 33 mU/L instead of 0.2 to 4.2 mU/L while lastly, her blood sugar was 4.5 nmol/L which was also normal.
On the basis of the findings of her history and results from the entire investigation, she was analyzed with the Addison’s disease. An issue of the autoimmune polyendocrine syndrome was raised due to her history of positive gastric parietal cell, Addison’s disease and hypothyroidism.
Causes of autoimmune adrenal insufficiency
*Features (order of frequency)*
Chronic mucocutaneous candidiasis Primary hypogonadism
Hypothyroidism Malabsorption syndromes Type 1 DM Others
Adrenal insufficiency Autoimmune thyroid disease Type 1 DM Primary hypogonadism Vitiligo
Isolated Autoimmune adrenalitis
*Lab findings and clinical manifestations.*
Weakness, fatigue (100%) Anorexia (100%) GI symptoms: Nausea (85%) Vomiting (74%) Constipation (34%) Abdominal pain Fever (acute onset) Salt craving
Diarrhoea Postural dizziness Myalgia Arthralgia
Dehydration (acute onset) Weight loss (100%) Hyperpigmentation (94%) Hypotension (SBP<110) shock (acute onset) Vitiligo Hyponatremia Hyperkaliemia Hypercalcemia Metabolic acidosis (acute onset) hypoglycemia Azotemia (acute Onset) Anaemia Lymphocytosis eosinophilia *Replacement therapy for glucocorticoid.*