CASE 1

Mang Tibo, a 55 year old male was diagnosed 6

years ago to have pulmonary tuberculosis but was only
able to complete 2 months anti-Kochs treatment. Two
years ago he noticed progressive weight loss. He
experienced asthenia most of the time.
Hyperpigmentation developed over the elbows and palm
creases. A day prior to admission, he experienced ill-
defined abdominal pain with diarrhea. He was brought to
a nearby lying-in clinic and was started on intravenous
fluids. However, he was noted to be persistently
hypotensive in spite of fluid replacement. He was
transferred to MCU-FDTMF Hospital. BP=80/40,
HR=125/min, RR=30/min.
Male, 55 years old
Diagnosed PTB 6 years ago
Completed 2 months of Anti-Kochs treatment
Weight loss 2 years ago
Asthenia most of the time
Hyperpigmentation on elbow and palm creases
Had ill-defined abdominal pain
Diarrhea
Persistent Hypotensive inspite administration of IV
Fluids
Decreased BP of 80/40
Increased heart rate of 125/min
Increased respiratory rate of 30/min

Life-threatening
Exacerbation of adrenal insufficiency leading to
insufficient cortisol - a hormone produced by the
adrenal glands
The patients history of pulmonary tuberculosis
predisposed him to develop primary adrenal
insufficiency.
Since he was not able to continue his anti-Kochs
treatment for 6 months, he might have progressed to
developing adrenal crisis.
Suggestive of Adrenal Crisis Not Suggestive of Thyrotoxicosis
Diarrhea None
Abdominal pain
Hypotension
Progressive weight loss
Skin pigmentation
Tachypnea
Tachycardia
This is a state when there is excessive quantity
of endogenous or exogenous thyroid hormone.

Suggestive of
Thyrotoxicosis
Not Suggestive of Thyrotoxicosis
Weakness (asthenia) Abdominal pain
Progressive weight loss Hyperpigmentation of palmar creases and
elbows
Diarrhea Hypotension
Tachycardia (HR 125
beats/min)
Tachypnea (?)
TB Infection (6 years ago)
Hematogenous spread
Lodge to adrenal glands
Destruction of adrenal glands
Adrenals fail to secrete its
hormones
Decreased
mineralocorticoids
H-P-A axis sense
decrease in adrenal
hormones (cortisol)
Decreased
glucocorticoids
Decreased mineralocorticoids
Decreases Na
+
reabsorption

Decreased ability to concentrate
urine
Decreased circulatory volume
Hypovolemia (BP 80/40mmHg)
Increased HR (125 beats/min)
Increased RR (30 breaths/min)
Increased
serum K+
level

Increased
GI motility

Abdominal
pain

Diarrhea

H-P-A axis sense decrease in
adrenal hormones (cortisol)
Negative feedback stimulation

Increased ACTH production by PG

Pigmentary changes occur due to
ACTHs intrinsic MSH activity
Hyperpigmentation of elbow and
palmar creases
Decreased glucocorticoids
Decreased
appetite

Decreased
gluconeogenesis

Decreased
CHON synthesis

Decreased induction
of insulin secretion

Progressive
weight loss

Decreased
energy
production

Asthenia