A 58-year-old previously fit and well man presented with sudden onset severe epigastric pain associated with frequent episodes of vomiting. The pain was constant and relieved only with morphine. He was febrile otherwise systemic examination was normal. Serum sodium 132 mmol/l and serum potassium 4.4 mmol/l. The rest of blood testes including; full blood count, liver functions, glucose, amylase, corrected calcium, D-dimer, troponin, urea and creatinine were all normal. ECG, chest X-ray and abdominal X-ray were unremarkable. On further review, it was noted that he was extensively tanned and pigmented with few patches of vitiligo that he never noted before. He had a significant postural drop of his blood pressure. Furthermore he revealed that he was feeling sleepy and tired most of the time.
His 0900 h cortisol was 59 nmol/l and ACTH 406 ng/l. Short synacthen test showed a flat response. Further investigations showed; Free T4 5.5 pmol/l, TSH 49.22 μ/l, Testosterone 5.4 nmol/l, LH 3.8 IU/l and FSH 3.8 IU/l. These investigations confirmed that he had primary adrenal failure, primary hypothyroidism and hypogonadism. Therefore, he was diagnosed as having autoimmune polyglandular syndrome type 2 and was commenced on replacement treatment. Two years follow up he remains in full time job and both his sons developed hypothyroidism. Lessons to be learned from this case are:
i)The diagnosis of Addisons disease is often delayed due to non-specific nature of its presentations and this case report highlights the importance of high index of suspicion in relevant settings to make a diagnosis.
ii)Severe abdominal pain which could present as an apparent acute abdomen is a well recognised feature of addisonian crisis.
In Polyglandular syndrome it is important to identify and treat adrenal failure prior to treating hypothyroidism with Thyroxine as this could lead into addisonian crisis.