This 16 year old Female, D/O well known pediatricians (both parents) has come to me for compliant of nausea, vomiting since last 15 days. This problem was there since last twelve month during her periods and used to get better afterwards. Since last 10 days she has anorexia, strong distaste for food and whatever she eats vomits immediately so she stopped eating. She was taking water and juices since last 3 days that too she was vomiting often. Last 24 hours she has complaint of giddiness and was feeling very weak so they came to me. She was seen by couple of physicians & OBG. She came with normal USG abdomen, CBC and prolactin reports. O/E I found her dull weak and does not even want to see food. Pulse 120/min , BP 90/60, RR 14, SPO2 100%, RBS 80. Other general and systemic examination are unremarkable. No response to antacids and antiemetics. Mother has RA negative small joint arthritis and DM.
My approach after history and examination was to find organic cause before labeling it psychogenic . As history was related to perimenstrual period and there was no significant weight loss my though was to look for hormonal cause 1st and then go for other metabolic disturbance . In this list corticosteroid deficiency , prolactinoma, porphyria, DKA, Insulinoma hypothyroidism/ hyperthyroidism comes. We got cortisol, ACTH, TSH, insulin, Na, K, insulin level . 6 am. Cortisol level was < 1 micrgram / dL & ACTH 5 pg/M L . Sort syncthen test confirmed the diagnosis of adrenal suppression .Got her MRI & CT abdomen done( normal) . Endocrinologist diagnose this ADRENAL FATIGUE. Started on tab hydrocortisone and patient responded immediately .
DX -Relative adrenal insufficiency ( Adrenal fatigue)
Case 2- This 46 year young gentleman came to me with complaints of backache and fluctuating pain in both the calf and thigh muscles since last 6 months. He has been seen by spine surgeon who has advised to get MRI LS SPINE. Two times MRI done in last six month is unremarkable . Patient was given steroid injection two times which could not relieve the pain. He has problem of constipation , anorexia despite that his weight is static . He is taking thyronorm 100 mcg, metoprolol 25 mg . A month ago he has complaint of urinary retention for which he needed urethroscopy and was prescribed doxy for 6 weeks ( could not understand why). Only reason to come to me was unbearable backache, leg pain which is giving sleeplessness night . O/E he is able to squate , and able to touch his both the toes. He has come with book of reports which was showing ESR ( 20-30), CRP 15-20) , TSH very low rest of the reports were normal. MRI LS spine was showing mild protrusion protrusion at L5 S1 which as per opinion of spine surgeon was normal. His vital are normal and despite anorexia and severe constipation he has gained weight 3 kg in last 6 months.
After examination my initial thought was to to find the cause . His blood reports were showing high eosinophils , ESR & low TSH . One of the rule of thumb which I always follow is whenever someone is on thyroxin tablets , ( TFT is so well control that TSH is low ) and patient is having paradoxical symptoms I will look for cortisol level . I also wanted to rule autoimmune and neuromuscular problems. I have asked for 6 a.m. cortisol , ANA,RA, NCV& EMG . Cortisol level came < 0.5 •μgm/dl and rest of the report were normal. Sort synacthen test confirmed the reports of severe adrenal insufficiency of adrenal origin . On retrospective questioning he has confirmed that he was taking Aurvedic medicine for weight gain . Steroid replacement has made him better. I have also reduced eltroxin dose to half.
Dx was secondary adrenal insufficiency . He needed 20 mg of wysolne to relieve his symptoms.
