A 25 year old man, with no significant past medical history and on no medication, presented to Accident and Emergency with collapse. He was anuric, hypotensive, with a sodium of 107 and a potassium of 8.8. Electrocardiographic changes showed widening of the QRS complex and tall tented T waves. He was in prerenal renal failure with a creatinine of 377 and urea of 36.9.
This presentation came after a week of feeling non-specifically unwell, progressive fatigue, weakness and anorexia, with 2 days of vomiting and diarrhoea. The patient was treated with IV hydrocortisone and fluid rehydration. However despite normalisation of his creatinine his electrolytes proved relatively resistant to treatment, taking nearly a week to return to the normal range.
On further questioning, the patient remembered having visited his GP a few months previously with tiredness. At that time, he had been noted to be mildly hypotensive, sodium 129, potassium 5.0, creatinine 127 and urea 9.2. He also commented that his friends had noticed that his fair skin, prone to burning in the past, had a nice tan this year. Furthermore, his palmar creases were noted to be hyperpigmented during his admission.
Although an initial serum cortisol was lost due to lab error, his ACTH was 1410. A formal diagnosis of Addisons Disease was confirmed when there was no rise in his plasma cortisol in response to a synacthen test this diagnosis was further supported by the presence of serum anti-adrenal antibodies. The patient is currently well, with normalised electrolytes and good renal function on Hydrocortisone replacement.
This case is an example of a life threatening presentation of Addisons Disease and highlights the importance of investigating mildly abnormal biochemistry in patients who are otherwise well.