Addison's Disease and Eosinophilia

Presentation Number: SUN 366
Date of Presentation: April 2nd, 2017

Mohd Bahari Kassim*
Plymouth Hospitals NHS Trust, Plymouth, UNITED KINGDOM

Abstract

This independent 88 year old gentleman who lives alone, was admitted with collapse, found on the floor by his carer. He felt lightheaded after getting up to use his commode and then fell to the floor. He has had multiple falls in the past with equivocal cardiac investigations. His co-morbidities include primary hypothyroidism with poor compliance (TSH 52), epilepsy, Parkinson's disease, hypertension and prior IHD with MI and PCI.

He is on multiple medications including Adcal D3, Levetiracetam, Sodium Valproate, Sinemet, Cetirizine, Aspirin, Atorvastatin, Clopidogrel, Ferrous Sulphate, Folic acid, Thyroxine, Furosemide and Fludrocortisone.

Examination revealed a slight drop in postural blood pressure from SBP 136mmHg to 105mmHg which was not significant. There were clinical signs of left lower lung consolidation consistent with chest radiography findings and raised CRP.

He had a seizure with hypomagnesaemia and hyponatraemia, Na from 134 to 127 mmol/l. Serum Osmolality is 272 mmol/kg and urine Osmolality is 367 mmol/kg

He had persistent eosinophilia for a few months up to 2.5 *109/L. There was no hypercalcaemia.

His 9am cortisol was suboptimal at 129 nmol/l. A subsequent synacthen test showed a serum cortisol of 139 nmol/l at baseline and 418 nmol/l at 30 minutes and 455 nmol/l at 60 minutes. Serum ACTH was not done until he was already started on Hydrocortisone at 7. Anti-adrenal antibodies were negative. Serum B12 was normal at 414. HbA1c was 46 mmol/mol.

His serum Aldosterone was 55 (26-339 pmol/l) and renin was 13.9 (4.0-47.4 mU/L).

Poor compliance with Thyroxine led to his serum TSH to vary from 31.4 to 52 mU/L.

He was commenced on Hydrocortisone replacement therapy of 15mg at 8am and 5 mg at 5pm; initially he was given 100mg Hydrocortisone intramuscularly as a stat dose. He was adequately rehydrated. His serum sodium started to improve to baseline 136 mmol/l as well as the eosinophilia to 0.2*109/L.

He was provided with a steroid card, MedicAlert bracelet forms and rehearsed the steroid rules.

Discussion.

This is a case that illustrates an unusual feature of Addison's disease with eosinophilia. The patient presented with collapse associated with seizure activity with hyponatraemia and hypomagnesaemia complicated by chest sepsis with chest X-ray changes. Even after treating the chest infection with intravenous antibiotics and oxygen, the hyponatraemia persisted. The chest physicians reviewed the patient in view of possible eosinopillic pneumonitis but this was subsequently excluded.

The combination of eosinophilia, collapse from hyponatraemia, element of postural blood pressure drop should alert one to possibility of hypoadrenalism. The hyponatraemia is not that convincing but nevertheless, exclusion of hypoadrenalism should be part of hyponatraemia work up. Vigilance of Addison's in eosinophilia should be considered.

 

Nothing to Disclose: MBK