A 28 year old man with a background of hypothyroidism presented to hospital following a collapse. He had a one week history of unrelenting vomiting with malaise. On examination, he appeared dehydrated and was profoundly hypotensive with a blood pressure of 56/25 mm Hg. General examination was otherwise unremarkable. The blood tests demonstrated acute kidney injury with serum creatinine 227 mmol/L and hyponatraemia with serum sodium 130 mmol/L. His potassium was within normal limits. His thyroid function tests showed raised TSH 6.21 u/L with a normal free T4. The remainder of his blood tests including bicarbonate, liver function tests, serum amylase and full blood count were all normal. Blood tests, Imaging and surgical opinion have excluded an acute abdomen and septic shock was unlikely. Therefore he was treated for severe dehydration due to gastroenteritis. Despite of 7 liters of fluid resuscitation and intropic support he remained profoundly hypotensive. Therefore he was empirically given Hydrocortisone intravenously on a regular basis, after which he had remarkable improvement. By day five he normalized his renal function. He became hypotensive again once the Hydrocortisone was withdrawn. Short synacthen test revealed that 9 am Cortisol was 17 nmol/l, 30 minutes Cortisol was 19 nmol/l. This flat response confirmed adrenal failure. A combination of Addison's disease and autoimmune hypothyroidism, (TPO Antibodies was 406.6 IU/L) is suggestive of Autoimmune Polyglandular Syndrome Type 2. Learning points:
Gastrointestinal symptoms as an apparent acute abdomen and circulatory failure are well recognised features of Addisonian crisis.
The diagnosis of Addisons disease requires a high index of clinical suspicion in relevant settings.
In Polyglandular syndrome it is important to identify and treat adrenal failure prior to treating hypothyroidism with Thyroxine as this could precipitate Addisonian crisis.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.