PBL4: 

Adie Hyteefor 
Adie Hyteefor is a 53-year-old Afro-Caribbean teacher who presented at her GP’s
surgery with a six-month history of weight loss and fatigue, with occasional palpitations
and increased anxiety. On examination she has a heart rate of 110 bpm and a bilateral
neck swelling. She reports that she constantly feels hot despite the onset of winter. Her
GP takes a blood sample which demonstrates the following.
Parameter  Value  Reference range: 

TSH  <0.01 mU/L  0.3 to 3.5 mU/L 

Free T4  45 pmol/L  11-25 pmol/L 

Free T3  8 pmol/L  3.5-7.5 pmol/L 

Anti-TPO  240 IU/ml  < 9.1 IU/mL 

Anti-TSHR  12.3  < 0.91 unit/l 

She is referred to see an endocrinologist. Adie’s endocrinologist discusses medical and

surgical options for treatment, but Adie prefers to start a tablet. After 6 months of
treatment her anxiety, palpitations and heat intolerance have resolved, but she still feels
tired and is having difficulty gaining weight. She reports increased skin pigmentation,
especially visible on the palms of her hands. She attends clinic one morning having
skipped breakfast and has a dizzy spell on arriving in the waiting room. Her BP is
104/82 but drops to 74/40mmHg on standing up. Her endocrine doctor admits her to the
ward for an infusion of intravenous fluid and arranges further blood tests. The anion gap
is calculated.

Parameter  Value  Reference range: 

 TSH  3 mU/L  0.3 to 3.5 mU/L 

Free T4  15 pmol/L  11-25 pmol/L 

Free T3  4 pmol/L  3.5-7.5 pmol/L 

9am Cortisol   45 nmol/l  110 - 607 nmol/L 

ACTH  240 ng/l  9am < 50ng/l 

Aldosterone  85 pmol/l  100 – 800 pmol/l 

Renin  7.0  0.5 - 3.5 nmol/L/h 

Na+ 131 133 – 146 mmol/L

K +  5.5 3.3 - 5.3 mmol/L

Cl- 108 98-106 mml/L

HCO3-  15 mmol/L 24 – 28 mmol/L 

Glucose  3.4 mmol/L 4-11 mmol/L

21-hydroxylase antibodies  positive  negative 

 
She is prescribed hydrocortisone and fludrocortisone tablets, and over the coming
weeks her symptoms improve, and her skin returns to normal. She is warned that if she
becomes unwell, she must double her dose of one of those medicines and given an
injectable version to take home for emergencies.