Skip to main content

Main menu

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
SynopsisC

Her tongue tipped us off…

Chantelle Barnard, Ronik Kanani and Jeremy N. Friedman
CMAJ August 31, 2004 171 (5) 451; DOI: https://doi.org/10.1503/cmaj.1040630
Chantelle Barnard
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ronik Kanani
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jeremy N. Friedman
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Responses
  • Metrics
  • PDF
Loading

A 15-year-old previously healthy girl presented to a tertiary care pediatric hospital emergency department in the fall with a history of vague right-sided pleuritic chest pain and dizziness. For the previous few months, she had been experiencing anorexia (with a 7-kg weight loss), epigastric discomfort and fatigue. Upon further questioning, the patient's mother stated that her daughter's summer suntan had not faded even though she had spent most of the previous month indoors. In addition, she was drinking up to 3 L of water a day and craving salty foods and pickles. On physical examination, her blood pressure was 90/50 mm Hg supine and 80/40 mm Hg sitting, her heart rate was 100 beats/min, her respiratory rate 16 breaths/min, and she was afebrile. Her skin was tanned and she had areas of hyperpigmentation on her tongue (Fig. 1). She had a slightly low sodium level (133 mmol/L) and a high normal potassium level (5.0 mmol/L). She was euglycemic and had evidence of mild prerenal failure (creatinine level 123 μmol/L and urea level 10.7 mmol/L). She had a high normal leukocyte count (10.3 х 109/L) with an elevated eosinophil count (1.34 х 109/L), mild anemia (hemoglobin 123 g/L) and a normal platelet count (362 х 109/L). Her erythrocyte sedimentation rate was elevated at 31 mm/h. A random cortisol level was low at < 25 nmol/L, which, despite variation in normal values, is highly suggestive of adrenal insufficiency. She had a normal chest radiograph and electrocardiogram. She was given a normal saline bolus to treat her hypotension and admitted to hospital for further investigation. An adrenocorticotropin hormone (ACTH) stimulation test revealed serum cortisol levels of 25 nmol/L at baseline and 27 nmol/L at 60 minutes (normally 165–680 nmol/L in the morning; the peak cortisol level with an ACTH stimulation test should be > 500 nmol/L). She was found to have primary adrenal insufficiency and given hydrocortisone and fludrocortisone. In hospital her symptoms improved, and her electrolyte level and renal function returned to normal.

Figure
  • Download figure
  • Open in new tab
  • Download powerpoint

Figure 1.

Primary adrenal insufficiency, or Addison's disease, was first described by Thomas Addison in 1855. In North America it is most commonly caused by autoimmune destruction of the adrenal gland by antiadrenal autoantibodies.1 This condition can be either isolated or associated with a polyglandular autoimmune endocrinopathy of the parathyroid gland, thyroid gland or pancreas.2 The incidence of primary adrenal insufficiency is 4.7–6.2 per million in white populations,3 with peak incidence in the fourth decade; women are affected more frequently than men.2 Symptoms of Addison's disease are nonspecific and may mimic malignant disease as well as gastrointestinal, psychiatric and other endocrine disorders. Salt craving is a more specific symptom of Addison's disease and occurs in about 15% of cases.3 Hyperpigmentation, a relatively specific sign, occurs in 94% of cases4 and is most pronounced in areas that are exposed to increased friction (e.g., palmar creases, knuckles, scars and oral mucosa). This finding is caused by increased ACTH and melanocyte stimulating hormone secondary to the compensatory activation of the hypothalamic– pituitary axis. Most patients who have adrenal insufficiency have a low random cortisol level at the time of diagnosis, but some may have a normal serum cortisol level; in this case, an ACTH stimulation test is required to confirm the diagnosis. Mild anemia, lymphocytosis, eosinophilia and hypoglycemia may also occur. Mineralocorticoid deficiency causes hyponatremia and hyperkalemia in 90% and 65% of patients respectively.3 Dehydration and prerenal failure may also occur.

Treatment of Addison's disease includes cortisol and mineralocorticoid replacement therapy. Ideally, a cortisol level should be obtained before therapy, but treatment should never be delayed if there is a strong clinical suspicion of adrenal crisis, which is life-threatening and may present with acute abdominal pain, vomiting, hypotension and hypovolemic shock. Although Addison's disease is rare, it is potentially life-threatening, and there shoul d be a high index of suspicion in patients with nonspecific symptoms but specific physical findings such as hyperpigmentation.

Chantelle Barnard Ronik Kanani Jeremy N. Friedman Division of Pediatric Medicine Department of Pediatrics University of Toronto Faculty of Medicine and the Hospital for Sick Children Toronto, Ont.

References

  1. 1.↵
    Betterle C, Dal Pra C, Mantero F, Zanchetta R. Autoimmune adrenal insufficiency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction. Endocr Rev 2002;23:327-64.
    OpenUrlCrossRefPubMed
  2. 2.↵
    Arlt W, Allolio B. Adrenal insufficiency. Lancet 2003;361:1881-93.
    OpenUrlCrossRefPubMed
  3. 3.↵
    Kong MF, Jeffcoate W. Eighty-six cases of Addison's disease. Clin Endocrinol 1994;41:757-61.
    OpenUrlPubMed
  4. 4.↵
    Larsen PR, Kronenberg HM, Melmod S, Polonsky KS. Williams textbook of endocrinology. 10th ed. Philadelphia: WB Saunders; 2002.
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 171 (5)
CMAJ
Vol. 171, Issue 5
31 Aug 2004
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Her tongue tipped us off…
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Her tongue tipped us off…
Chantelle Barnard, Ronik Kanani, Jeremy N. Friedman
CMAJ Aug 2004, 171 (5) 451; DOI: 10.1503/cmaj.1040630

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Her tongue tipped us off…
Chantelle Barnard, Ronik Kanani, Jeremy N. Friedman
CMAJ Aug 2004, 171 (5) 451; DOI: 10.1503/cmaj.1040630
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • References
  • Figures & Tables
  • Responses
  • Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Short ACTH stimulation test for adrenal reserves of cortisol, not adrenal function
  • Short ACTH stimulation test for adrenal reserves of cortisol, not adrenal function
  • Google Scholar

More in this TOC Section

  • Does β-blocker prophylaxis improve survival after major noncardiac surgery?
  • The changing ecology of avian flu
  • Applying the 2005 Canadian Hypertension Education Program recommendations: 4. Managing uncomplicated hypertension
Show more Synopsis

Similar Articles

Collections

  • Topics
    • Endocrinology

 

View Latest Classified Ads

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • CPD credits
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Advisory Panels
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions
  • Accessibiity
  • CMA Civility Standards
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: cmajgroup@cmaj.ca

Powered by HighWire