Endocrine Abstracts

Introduction: Addison’s disease is the commonest cause of primary hypoadrenalism in the western world. Here, we discuss a case of Addison’s with unusual presentation.

Case report: A 39-year-old woman with no previous mental health problems was admitted with history of worsening depression over the last 15 months following her divorce. She had low mood and anhedonia in spite of sertraline for more than a year. This was associated with 40 kg weight loss. She was on Beclomethasone and salbutamol inhalers for her asthma. She was cachectic and was profoundly hypotensive. Systemic examination was unremarkable. Her biochemistry revealed electrolyte abnormalities typical of Addison’s but she also had acute kidney injury with Creatinine 339 μmol/l (NR: 64–104). Hypoadrenalism was suspected which was confirmed by random cortisol of only 3 nmol/l. Commencement of hydrocortisone and IV fluid replacement led to clinical (including depression) and biochemical improvement. Subsequent investigations showed a high ACTH 24.8 ng/l (NR: 7–63) and positive anti-adrenal antibodies confirming the diagnosis of Addison’s disease. She was discharged home on hydrocortisone and Fludrocortisone.

Conclusion: Addison’s patients presenting predominantly with psychiatric symptoms is rare. The etiology of the neuropsychiatric symptoms remains unknown, but may involve electrophysiological, electrolyte and metabolic abnormalities, glucocorticoid deficiency, and high endorphins. Our case was particularly difficult as it was complicated by other elements (divorce) which appeared like the aetiology of depression for the treating primary care physicians. This highlights the fact that the clinicians should have high index of suspicion to look for other causes, if the depression is not responding to the usual antidepressants. Our patient also had acute kidney injury at presentation. About 55% of patients do have a degree of azotaemia but very few have been reported with such a drastic deterioration in renal function. The electrolyte abnormalities in Addison’s disease could easily be attributed to AKI and therefore physicians need to be vigilant.