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Lise Nilsen, age 35

Department of Wndocrinology
Made by Unni Syversen, 2003

Part 1
The patient has had type 1 diabetes for 8 years. Her diabetes has been treated
with a multi-injection regime and has been well regulated with a HbA1C at 7.5%
(4.3 --6.1%). She is now seeking medical advice because she has experienced
an increased frequency of hypoglycaemic episodes lately, in spite of unchanged
insulin dosage, food intake or level of physical activity. Further questioning
reveals that she has had other symptoms as well: diarrhoea, weight loss, fatigue
and hair loss.

Discussion I

• What would you look for in your clinical examination of this patient?
• Which blood tests would you order ?

Part 2
Clinical examination
35-year-old woman, slender, reduced general condition BP: 90/60, HR: 80.
The patient has increased skin pigmentation in the face and the furrows of the
palms.
Decreased body hair.
Otherwise normal clinical status.

Part 3

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Blood tests
Hgb 10.5 (11.5-15..5 g/dl)
WBC 8.4*10^9/L (3.7-10.0 )
SR 20.0 (1-21 mm)
Glucose 3.1 (3.7-5.7mmol/l)
Creatinine 95.0 (60-120 umol/l)
Sodium 132.0 (136-146 mmol/l)
Potassium 5.2 (3..5-5.0 mmol/l)
T4, free 9.5 (11-26 nmol/l)
TSH 6.2 (0.4-5.5 mIE/l)
Cortisol 8 a.m. 65.0 (200-700mmol/l)

Discussion II

• What is the most likely diagnosis considering these results?

• How will you further investigate this patient?

Part 4
The patient has an adrenocortical insufficiency, and the next step is to find out
whether it is primary or secondary. Based on the laboratory findings she also has
a slight hypothyroidism.

Further tests showed elevated serum levels of ACTH: 50,5 (2,0-11,4 pmol/l), and
increased titer for antibodies against adrenal cortex

Discussion III

• What is the most likely diagnosis considering the latest findings?

• Which examinations would you perform if serum ACTH was low?

Part 5
Conclusion.
The patient has a primary adrenocortical insufficiency (Addison`s disease).

Discussion IV

• What is the aetiology of adrenal cortex failure?

• What kind of treatment would you initiate?
• How would you treat the slight hypothyroidism?

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Part 6
Treatment and follow-up.
Treatment with cortisone 25 + 12.5 mg was started. At the follow-up 2 months
later, serum sodium level is 134 mmol/L and serum potassium is 4.9 mmol/L. The
patient complains of salt craving, and the treatment is complemented with
fludrocortisone (Florinef). The thyroid function tests are normalised.

Discussion V

• Further follow up of the patient?

• What advice would you give concerning cortisone dosage in situations that
place the body under stress?

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