Endocrine Abstracts

The non-specific symptoms of Addison’s disease may be attributed to other conditions with consequent delay in diagnosis. We describe such a case of novel presentation. A 61 year old female presented with a one-day history of vomiting, abdominal pain and 15kg weight loss over 6 months. PMH: hypertension of 15 years duration, chronic kidney disease (CKD3) for 7 years and hysterectomy for endometrial carcinoma 8 years earlier. Examination: dehydrated, sinus tachycardia 110 bpm, blood pressure supine 60/unrecordable mmHg. Investigations. Sodium 124 mmol/l, potassium 7.4 mmol/l, urea 35 mmol/l, creatinine 713 mmol/l, eGFR 5 ml/min (CKD 5), pH 7.2 and bicarbonate 14 mmol/l. Initial diagnosis was septic shock with acute on chronic renal failure. CT imaging, in view of previous malignancy, confirmed metastatic infiltration of adrenal glands. A cortisol level of 136 nmol/l supported a diagnosis of Addisonian crisis (confirmed by ACTH 1573.0 ng/l and Short Synacthen test cortisol: 0min 234, 30min 345, 60min 250 nmol/l). Previous records revealed admissions 8, 6 and 3 weeks previously with worsening hypotension and deteriorating renal function despite treatment with amlodipine, atenolol and doxazosin being stopped on the second admission. Treatment with IV hydrocortisone followed by oral hydrocortisone and fludrocortisone resulted in rapid clinical and biochemical improvement with renal function returning to baseline CKD 3. She died of metastatic disease 3 months later. Whilst anorexia, vomiting, weight loss, skin pigmentation and similar biochemical abnormalities occur in Addison’s disease and renal failure, hypotension and dehydration are uncommon in the latter. That the progressive renal failure in this case was due to dehydration and hypotension consequent to progressive loss of adrenal function was confirmed by its reversal on treatment with hydrocortisone and fludrocortisone. We advocate assay of cortisol in cases of hypotension even when aetiology is apparently defined.