May 2019 | Case of the Month

The diagnosis is Addisons disease, which was confirmed by the endocrinologists to who I had urgently referred the patient.
 

Features of Addisons include:

• Systemic features
  • Include fatigue, weight loss, dizziness on standing, abdominal pain, vomiting and psychiatric symptoms
• Hyperpigmentation
  • Affects UV-exposed sites, palmar creases, buccal mucosa, gums, scars, hair and nails, areas subject to friction
  • There is accentuation of normally high pigmentation areas such as the areolae, axillae, genital skin and umbilicus
• ​Investigations
  • Low serum sodium and raised serum potassium
  • Serum urea and albumin are raised because of dehydration
  • Serum cortisol level taken ideally between 8-9 am (random measurements have a low sensitivity for Addison's disease due to the pulsatile nature and diurnal variation of cortisol secretion). If the level of serum cortisol is:
    • < 100 nanomol/L - adrenal insufficiency is highly likely (if the patient is not on oral or inhaled steroids)
    • > 400 nanomol/L - adrenal insufficiency is unlikely (diagnosis not excluded if the patient is acutely unwell at the time since cortisol values may increase during illness)
    • Between 100 and 400 nanomol/L - refer to a specialist for further investigations eg synacthen test

For more information on the causes of facial hyperpigmentation click on the link.