Endocrine Abstracts

Introduction: The coexistence of hyperthyroidism and adrenal insufficiency in the same individual is a rare clinical condition.A total of 20 cases has been reported in the literature [1]. These two conditions may have the same clinical manifestations such as weight loss, asthenia, and digestive disorders and each one may mask the other. We describe the case of a patient presenting to the emergency department with acute adrenal insufficiency in whom associated hyperthyroidism was discovered.

Case report: A 69-year-old woman presented to the emergency department with asthenia, abdominal pain, vomiting, and a rapidly worsening neurological state leading to mental confusion. In her history, we note a diabetes evolving for 10 years in stop of treatment. T e examination noted an altered general condition with significant weight loss, dehydration without associated hemodynamic or respiratory failure. The presence of exophthalmos and a moderate vascular goiter was noticed. There was no melanoderma. Cardiac tracing revealed atrial fibrillation. The biology showed a venous blood glucose of 8.7 mmol/l, a natremia of 125 mmol/l, a hyperkalemia of 6.29 mmol/l, a renal insufficiency with creatinine of 136 μmol with hyperuremia of 62 mmol/l. So, a cortisolaemia and a TSH were requested and the patient had an emergency hemodialysis session and was put on corticosteroids by intravenous route with clinical and biological improvement. Results of cortisolaemia were of 17.47ug/l and the diagnosis of adrenal insufficiency was retained. TSH was requested, which was reduced to 0.001 mIU/l (0.3-5.6) with an increased FT4 to 64.31pmol/l (7.8-14.8). Anti-TPO antibodies were strongly positive at 602 IU/ml. The patient was transferred to our endocrinology department. The patient was put on synthetic antithyroid drugs, betablockers and oral hydrocortisone therapy.

Discussion: This case illustrates the precipitation of an acute adrenal insufficiency crisis by an unrecognized thyrotoxicosis condition. This can be explained by the fact that thyroid hormones accelerate cortisol metabolism [2]. Thyrotoxicosis increases metabolic demands and induces a state of stress which results in an increased need for cortisol which cannot be procured in case of adrenal insufficiency [2].

Conclusion: It is crucial to consider the diagnosis of adrenal insufficiency in renal insufficiency patients. It is also predijuciable to consider the diagnosis of thyrotoxicosis in some patients having adrenal insufficiency, selected by a well-conducted examination.

References: [1] https://pmj.bmj.com/content/postgradmedj/43/496/129.full.pdf [2] M. A. Mushref, M. Caldwell, and E. Harris, "Adrenal Crisis Triggered by Endogenous Thyrotoxicosis: Case Series," AACE Clin.