Endocrine Abstracts

Background: Syncope is common in healthy adolescents and young adults. It can happen due to hypotension secondary to orthostasis. Primary adrenal insufficiency is infrequently reported in patients presenting with syncope and dizziness caused by loss of vasopressor effect of catecholamines and volume depletion.

Clinical Case: A 17-year-old boy with a past medical history of learning disability and asthma presented to our health facility with an episode of syncope. He felt dizzy on standing and had transient loss of consciousness at the General Practitioner (GP) Surgery. He was feeling unwell and nauseous for past several days. His physical examination revealed darkening of skin (pigmentation) but rest of the examination was unremarkable. Initial baseline investigations including blood glucose were normal except mild hyponatremia with sodium levels of 134 mmol/l (135–145). CT scan of thorax, abdomen and pelvis was unremarkable. He was referred to the endocrinologist with a clinical impression of primary adrenal insufficiency. Further investigations including serum ceruloplasmin and iron studies were normal. Short synacthen test revealed cortisol levels of 46 nmol/l and 40 nmol/l at 30 and 60 minutes respectively. Adrenal antibodies were weak positive. He was treated as auto-immune adrenal insufficiency or Addison’s disease and given mineralocorticoid (fludrocortisone) and corticosteroids (hydrocortisone) regimen. Careful history taken with his mother revealed that he had vitiligo in the past but denied any significant family or drug history. His previous investigations showed high levels of TSH at different times ranging from 2.69 to 45.18 mIU/l (0.51–4.30). Anti TPO antibodies were tested and found significantly raised with a value of 220 IU/ml (0–40). The patient was given the diagnosis of autoimmune polyendocrine syndrome type 2 (APS-2). He was advised screening for antibodies against IA-2, insulin, GAD65 to test for type 1 diabetes predisposition and tissue transglutaminase autoantibodies to screen for coeliac disease. His family was finding it difficult to absorb all these information and asked for some time before proceeding to further tests. He was advised endocrine clinic follow ups.

Conclusion: This case report highlights the importance of arriving at the right diagnosis as signs and symptoms can be vague and mimic other conditions. Appropriate investigations, treatment and follow up can improve quality of life.

Key words: syncope, adrenal insufficiency, auto-immune.