Addisons disease: Soy Sauce a lifesaving concoction
B Bhattacharya, A Ullah, WSA Smellie, A McCulloch & AH Heald
Background: Before synthetic cortisone was introduced, patients with Addisons disease prolonged their lives by maintaining a high salt intake and taking plant based containing preparations affecting steroid metabolism. We report the case of someone who discovered this regime for herself.
Case report: A 42 year old lady presented with a four week history of decreased energy, malaise, and postural dizziness. She was hyponatraemic (plasma sodium 126 mmol/l) with potassium 4.6 mmol/l and random glucose 4.9 mmol/l. Five years previously she was diagnosed with SIADH when working as a teacher in Brunei. Over subsequent years she developed a penchant for liquorice sticks and for Dragon Soy sauce, consuming two 250 ml bottles each week. A family history of Type 1 diabetes was reported. Examination revealed no stigmata of Addisons disease. Lying BP was 120/80 mmHg: no postural drop.
Investigations: Short Synacthen Test failed: Basal cortisol 271 nmol/l; 30 min cortisol 298 nmol (should rise to 550 nmol/l or more). Adrenal antibody highly positive. ACTH raised 76 ng/l (047). TFTs: Free T4 14 pmol/l (1023); TSH raised 8.4 mu/l (0.45.5). Oestradiol (542 pmol/l) and gonadotrophins (LH 3.5 mu/l, FSH 4.4 mu/l) were in the pre-menopausal range.
Management: Started on Hydrocortisone/Fludrocortisone with resolution of symptoms. TSH normalised to 2.9 mu/l; Free T4 14 pmol/l.
Discussion points: Our patient avoided any major crisis until 2005 thanks to ingesting 2 moles of sodium each week (analysis of the Soy sauce revealed: Na 4130 mmol/l, Cl 3137 mmol/l, K 20.8 mmol/l, Glucose 77.4 mmol/l) and bolstering mineralocorticoid levels by eating liquorice which contains glycyrrhizinic acid, an inhibitor of steroid breakdown. This highlights the value of a dietary history in such cases.