1. Unusual Tanning
By Chris Sanders

2. Chief Complaints Weaker and more tired over past 4 months
Severe increase in past week
Unable to enjoy outdoor activities
Unusual tan

3. History of Present Illness/Previous Medical History
Surgically treated appendicitis 10 years ago
Seroconverted to PPD (+) 6 years ago; treated for 12 months with INH
Pernicious anemia x 5 years
Hypercholesterolemia x 1 year; controlled with diet and exercise
48 year old white woman
Loss of appetite
Progressive fatigue
Mild nausea
PPD: purified protein derivative (tuberculin skin test)
INH: isoniazid
Pernicious anemia: Inability to absorb B12

4. Family History No history of cancer
Father died of cardiac arrest at age 65
Mother in nursing home following CVA; also RA
Two sisters with Hashimoto’s thyroiditis
One sister with Graves’ disease
One brother alive and well
CVA: cardiovascular accident (stroke)
RA: rheumatoid arthritis

5. What is the major significance of this patient’s family history?

6. The Common Factor Rheumatoid Arthritis Autoimmune Disease
Hashimoto thyroiditis
Autoimmune Disease
Graves’ disease
Autoimmune Disease

7. Meds
Cyanocobalamin, 200µg IM on 15th of each month (physician recently increased dosage)
ASA → swelling of face
TMP-SMX → bright red rash that covered her torso and face, reportedly with fever
Cyanocobalamin: B12 supplement
ASA: aspirin (acetylsalicylic acid)
TMP-SMX: trimethoprim-sulfamethoxazole (antifungal/antibacterial)

8. Cyanocobalamin Why is the patient taking this medication?
Vitamin B12 deficiency
Why is oral cyanocobalamin not an option for her condition?
Oral side effects may include hives, difficulty breathing, swelling of the face, headache, nausea, diarrhea

9. Review of Systems
(-) for fever, chills, shortness of breath, night sweats, and cough
(+) for weight loss of 6 pounds in the last month
(+) for salt cravings before nausea developed
(+) for several bouts of dizziness, one fainting spell in the last 6 months
(+) for few aches and pains
(-) for recent changes in vision
(-) for changes in menstrual cycle
(+) for prominent tanning of the skin, although she denies significant exposure to the sun

10. PE and Lab Tests
Tired-looking, tanned Caucasian woman in NAD who appears to be her stated age
BP 95/75, P 83/min sitting, right arm
T 98.0º F
BP 80/60, P 110/min standing, right arm
HT 5 ft-6½ in
RR 14/min
WT 124 lbs
Explain the significance of the varying blood pressure and heart rate readings with change in position by the patient.

11. PE and Lab Tests cont. Skin HEENT Intact, warm, and very dry
Subnormal turgor
Pigmented skin creases on palms of hands and knuckles
Generalized tanned appearance, even at sites not exposed to the sun
Sparse axillary hair
HEENT
PERRLA
EOMI
Normal funduscopic exam
TMs intact
Dry mucous membranes
Turgor: skin elasticity
HEENT: head, eyes, ears, nose, throat
PERRLA: pupils equal, round, and reactive to light and accommodation
EOMI: extra-ocular movements intact
TM: tympanic membrane

12. PE and Lab Tests cont. Neck Lungs Cardiac Breasts Abdomen
Supple with normal thyroid and no masses
Shotty lymphadenopathy
Lungs
Clear, normal vesicular and bronchial lung sounds to A&P
Cardiac
RRR
No m/r/g
Breasts
Equal in size without nodularity, masses, or tenderness
Very dark areolae
Hyperpigmentation prominent along brassiere lines
Abdomen
Soft and NT
(-) HSM
(+) BS
Lymphadenopathy: swelling of lymph nodes
RRR: regular rate and rhythm
m/r/g: murmur/rub/gallop
NT: non-tender
HSM: hepatosplenomegaly (liver and spleen enlargement)
BS: bowel sounds

13. PE and Lab Tests cont. GU Neuro MS/Ext Peripheral Blood Smear
Normal external female genitalia
LMP 2 weeks ago
Normal pelvic exam without tenderness or masses
Neuro
A & O x 3
Bilateral deep tendon reflexes intact at 2+
Normal gait
CNs II-XII intact
MS/Ext
No CCE
Normal ROM
Pigmented skin creases on elbows
Pedal pulses moderately weak at 1+
Muscle strength 5/5 throughout
Peripheral Blood Smear
Normochromic, Normocytic erythrocytes
GU: genitourinary
LMP: last menstrual period
A & O x 3: alert and oriented to person, place, and time
MS/Ext: Musculoskeletal/Extremities
CCE: clubbing, cyanosis, or edema
ROM: range of motion

14. Laboratory Blood Test ResultsNa
126 meq/L
Hct
33.2%
Alk Phos
115 IU/L K
5.2 meq/L
RBC
4.1 million/mm3
Bilirubin
1.2 mg/dL Cl
97 meq/L
MCV
85 fL
Protein
8.0 g/dL
HCO3
30 meq/L
Plt
410,000/mm3
Albumin
4.7 g/dL
BUN
20 mg/dL
WBC
6,800/mm3
Cholesterol
202 mg/dL Cr
Neutros
49%
Triglycerides
159 mg/dL
Glu
55 mg/dL
Lymphs
36% Fe
89 µg/dL Ca
8.8 mg/dL
Monos 7%
TSH
3.2 µU/mL
Phos
2.9 mg/dL
Eos
Free T4
16 pmol/L Mg
Basos 1%
Cortisol
2.0 µg/dL
Uric acid
3.6 mg/dL
AST
33 IU/L
ACTH
947 pg/mL Hb
11.4 g/dL
ALT
50 IU/L
Vitamin B12
700 pg/mL
Sodium is borderline critical, usual is meq/L
Potassium is high, usual is meq/L
Eosinophils very high, usual is 1-4%
Cortisol dangerously low, should be 5-20 µg/dL
ACTH: adrenocorticotropic hormone – Dangerously high, should be 9-52 pg/mL

15. PE and Lab Tests cont. UA Imaging Antibody Testing Clear and yellow
SG 1.016
pH 6.45
(-) blood
Imaging
Abdominal CT scan revealed moderate bilateral atrophy of the adrenal glands
Antibody Testing
(+) 21-hydroxylase
(-) 17-hydroxylase
(-) C-P450

16. What is your diagnosis?

17. Rapid ACTH Stimulation Test
Condition
Cortisol Assay
Aldosterone Assay
Pre-cosyntropin
2.0 µg/dL
3.8 ng/dL
30 min post-cosyntropin
1.9 µg/dL
Normal patient levels should double in 30 minutes
Diagnostic test to distinguish primary and secondary adrenal insufficiency
ACTH: adrenocorticotropic hormone – Dangerously high, should be 9-52 pg/mL

18. Closing Questions
What is the single greatest risk factor for Addison disease in this patient?
What is the most likely cause of Addison disease in this patient?
Why can tuberculosis be ruled out as a cause of Addison disease in this patient?
Which two test results are most suggestive of the cause of Addison disease in this patient?
Addison/Adrenal crisis: loss of consciousness, psychosis, convulsions, fever
Genetic factors
Problem free 5 years
Cortisol/ACTH levels

19. Closing Questions
Would supplementation with fludrocortisone be appropriate in this patient?
Does this patient have any signs of hypothyroidism, a disorder that is commonly associated with Addison disease?
There are 19 clinical signs and symptoms in this case study that are consistent with Addison disease. Identify 15 of them.
Which single test result is diagnostic for Addison disease in this patient?
Fludrocortisone might not be appropriate, since sodium is low and potassium is high
No signs of hypothyroidism
Tan, high K, low Na, low cortisol, high ACTH, familial history, fatigue, nausea, loss of appetite, shotty lymphadenopathy, increased eosinophils
ACTH stimulation

20. Closing Questions
Which test results support the assessment that the patient’s anemia is not the result of iron deficiency?
Which test results support the assessment that the patient’s anemia is not the result of vitamin B12 deficiency?
Why is shotty lymphadenopathy consistent with a diagnosis of Addison disease in this patient?
Sufficient iron
Sufficient B12
Immunological disorder