Pigmentation in Addison's disease

 

Scenario:

A male patient,55-year-old nonsmoker, nondiabetic, non-alcoholic presented with weakness, loss of appetite and weight loss, dizziness and generalized pigmentation for 1 year.

 

History:

Ask About pigmentation, distribution of it-focal or generalized, site of predilection (In our patient he has generalized pigmentation more marked in the tongue & palate)

 

Ask about weight loss, how much he has lost? what is present weight? if not measured then how does he ascertain weight loss? does his clothes become looser? Is the weight loss intentional or not? ask about food habit, induced vomiting, laxative, diuretic use.

(In our patient he lost about12 kg in last 1 year, which was unintentional)

 

Ask about dizziness-What does he mean by it? Is it lightheadedness, unsteadiness or spinning? in which position it is more, such as standing from sitting? does he know his blood pressure? if yes then what is during sitting or lying or during standing?

(In our patient he has dizziness during standing from sitting, he reported that his blood pressure is low but did not know the exact measurement)

 

Ask about loss of appetite such as its duration, in any specific food or to all foods? Is there any association with nausea vomiting etc. (In our patient he has loss of appetite to all foods)

 

Ask about associated gastrointestinal symptoms such as dysphagia, nausea/vomiting, abdominal pain, GI bleeding, bowel habit, steatorrhea etc. (None of the symptoms was present in our patient except nausea)

 

Ask about symptoms of TB such as prolong fever, cough, hemoptysis, anorexia etc. (No such history)

 

Search for vitiligo which may point to autoimmune disease. (Absent)

 

Ask about other disease such as CKD, CLD, Kala-azar, haemochromatosis where pigmentation may be seen. (Absent)

 

Take past medical history including DM, Thyrotoxicosis, Adrenalectomy or adrenal irradiation. See any features of depression. (No history of this type of illness)

 

Ask any member of the family suffering from this type of illness or other chronic condition. (In our patient All family members in good health)

 

Ask about past and present medication history specially steroids. (He is taking methylprednisolone 2mg tablet for his low blood pressure for last 6 month but his condition was not improving)

 

 

Physical Examination:

General examination

   In this patient we found that patient was emaciated, pigmentation in lip, tongue and palate. We have search other body parts such as palmar crease and knuckles, nipples, axilla, perineum or in surgical scar. Search for vitiligo, though it was absent in our patient.

 

His blood pressure was in sitting position 100/70mmHg but on standing it was 75/50mmHg (Postural Hypotension)

 

Other findings in GE was normal.

 

Systemic examination: Perform systemic examination including CVS, Respiratory system, Nervous system and MSK system. (Though in our patient all systemic examination were normal)

 

Provisional Diagnosis:

 

Considering the history and findings in clinical examination our Provisional Diagnosis is “Addison’s Disease”

 

 

Points in favor of our Diagnosis:

   1.Weakness, Weight loss, nausea

   2.Dizziness and postural hypotension

   3.Generalised pigmentation

 

 

 

 

 

 

Investigations:

 

 

FBC (for lymphocytosis, eosinophilia)

Electrolytes (for hyponatremia, hyperkaliemia, hyperchloremic acidosis,

hypercalcemia)

Blood glucose, looking for hypoglycemia

Short tetracosactrin (synacthen) test; if positive, follow-up with a prolonged

ACTH stimulation test

ACTH and cortisol levels: in Addison’s disease the 9 am ACTH is elevated

(>300 ng/l)

Adrenal autoantibodies: 21-hydroxylase autoantibodies are elevated in

80%

Chest radiography for TB

Plain radiograph of the abdomen for adrenal calcification

CT scan of the adrenals.

HIV Screening

We should screen for thyroid disease, pernicious anemia, type-1 diabetes if evidence of autoimmune adrenal failure.