Mrs. K, a 55-year-old woman, was admitted with recurrent vomiting for the past 5 months and generalized weakness. She had lost significant weight and could no longer perform daily activities. On examination, she was emaciated and had pigmentation on her skin. Tests found low sodium and potassium levels with high renin and aldosterone levels, consistent with adrenal insufficiency. The provisional diagnosis was hypertension and Addison's disease. Further tests were needed to confirm whether the condition was primary or secondary adrenal insufficiency.

1. AN ELDERLY LADY WITH RECURRENT
VOMITING AND GENERALIZED
WEAKNESS
Dr. Debasish Kumar Ghosh
Phase-B Resident, Endocrinology
BSMMU

2. Case Summary
Mrs. K
55 yrs
Shibpur, Shariatpur
Admitted on 24.06.13
Recurrent episode of vomiting for 5 months
Generalized weakness for same duration

3.  Accordingly, had been doing well 5 months
back
 Then developed recurrent episodes of
nausea, vomiting
typically occurring post-meal
non-projectile
contained only food material

4.  Episodes lasted for 5-10 days, never
recovered completely
 Became anorexic and lethargic
 with significant weight loss
 Could no longer perform daily
household activity

5.  Later on, complained of burning epigastric pain
no association with food
no radiation
not relieved by vomiting
 On query, noticed gradual pigmentation over
face
palmer surface of both hands

6.  H/0 3 times hospitalization for extreme
weakness and single episode of
aggressive behavioral change
 Diagnosed as hypertensive 4 months
back, but didn’t take prescribed anti-
hypertensive
 No H/O cold intolerance

7.  Bowel habit normal, no history suggestive
of TB
 Had menopause at the age of 50 yrs
 5 sons and 2 daughters
 No known autoimmune disease in family

8.  Every time on admission, treated with I/V
fluid, inj. Hydrocortisone
 Following discharge, was advised oral
prednisolon 2 weeks back, but didn’t
continue

9. On examination
 Emaciated
 Mildly anaemic
 Pulse : 86 beats/ min
 BP : 160/ 90 mmHg, no postural
drop
 Dehydration : mild

10.  Pigmentation more marked over face
palmer surface of both hands
abdomen
 No thyromegaly
 No lymphadenopathy

11. Systemic examination
 All systems were unremarkable

12. Provisional diagnosis
HTN and Adrenal insufficiency
( Addison’s disease)

13. Investigation profile
S. electrolyte
Electrolyte
s
9.02.13 3.05.13 24.06.13
Na +
102 mmol/L 110 mmol/L 115.8
mmol/L
K +
4.6 mmol/L 4.0 mmol/L 3.14
mmol/L
Cl -
78 mmol/L 78 mmol/L 79.8
mmol/L

14.  18.06.13 CBC
Hb 11.1 gm/dl
ESR 35 mm in 1st
hour
TC 7,100 /cmm
DC N - 80%
L - 15%

15.  19.03.13
24 hrs urine Na +
: 229.35 mmol/L
(40-220)
24 hrs urine K +
: 45.38 mmol/L(25-
125)
 14.03.13
S. osmolality : 225.8 mosmol/kg
Urine osmolalitly : 412.7 mosmol/kg

16.  5.03.13
S. basal cortisol : 8.10 μgm/dl
 29.06.13
Plasma ACTH : 11.5 pg/ml
 S.T4 : 12.7 µgm/dl
 S. TSH : 0.50 µIU/ml

17.  27.02.13
Endoscopy UGIT : erosive antral
gastritis with esophagitis with GERD
 19.06.13
USG W/A : soft calculus
cholelithiasis
and bile sludge in GB

18.  MRI of brain : Empty sella

19. Problem list
 Whether vomiting is due to adrenal
insufficiency or erosive gastritis?
 If adrenal insufficiency, then is it
primary or 2ndary?
 What to be done next for confirmatory
diagnosis ?

20. Thank You