Unusual TanningBy Chris Sanders

Chief Complaints

Weaker and more tired over past 4 months

Severe increase in past week

Unable to enjoy outdoor activities

Unusual tan

History of Present Illness/Previous Medical

History

48 year old white woman

Loss of appetite

Progressive fatigue

Mild nausea

Surgically treated appendicitis 10 years ago

Seroconverted to PPD (+) 6 years ago; treated for 12 months with INH

Pernicious anemia x 5 years

Hypercholesterolemia x 1 year; controlled with diet and exercise

Family History No history of cancer

Father died of cardiac arrest at age 65

Mother in nursing home following CVA; also RA

Two sisters with Hashimoto’s thyroiditis

One sister with Graves’ disease

One brother alive and well

What is the major significance of this

patient’s family history?

The Common Factor

Rheumatoid Arthritis Autoimmune Disease

Hashimoto thyroiditis Autoimmune Disease

Autoimmune Disease Graves’ disease

Meds Cyanocobalamin, 200µg

IM on 15th of each month (physician recently increased dosage)

ASA → swelling of face

TMP-SMX → bright red rash that covered her torso and face, reportedly with fever

Cyanocobalamin

Why is the patient taking this medication?

Vitamin B12 deficiency

Why is oral cyanocobalamin not an option for her condition?

Oral side effects may include hives, difficulty breathing, swelling of the face, headache, nausea, diarrhea

Review of Systems (-) for fever, chills,

shortness of breath, night sweats, and cough

(+) for weight loss of 6 pounds in the last month

(+) for salt cravings before nausea developed

(+) for several bouts of dizziness, one fainting spell in the last 6 months

(+) for few aches and pains

(-) for recent changes in vision

(-) for changes in menstrual cycle

(+) for prominent tanning of the skin, although she denies significant exposure to the sun

PE and Lab Tests Tired-looking, tanned Caucasian woman in

NAD who appears to be her stated age

Explain the significance of the varying blood pressure and heart rate readings with change in position by the patient.

BP 95/75, P 83/min sitting, right arm

T 98.0º F

BP 80/60, P 110/min standing, right arm

HT 5 ft-6½ in

RR 14/min WT 124 lbs

PE and Lab Tests cont.

HEENT PERRLA EOMI Normal funduscopic

exam TMs intact Dry mucous membranes

Skin Intact, warm, and very

dry Subnormal turgor Pigmented skin creases

on palms of hands and knuckles

Generalized tanned appearance, even at sites not exposed to the sun

Sparse axillary hair

PE and Lab Tests cont. Neck

Supple with normal thyroid and no masses

Shotty lymphadenopathy

Lungs Clear, normal vesicular

and bronchial lung sounds to A&P

Cardiac RRR No m/r/g

Breasts Equal in size without

nodularity, masses, or tenderness

Very dark areolae Hyperpigmentation

prominent along brassiere lines

Abdomen Soft and NT (-) HSM (+) BS

PE and Lab Tests cont. GU

Normal external female genitalia

LMP 2 weeks ago Normal pelvic exam

without tenderness or masses

Neuro A & O x 3 Bilateral deep tendon

reflexes intact at 2+ Normal gait CNs II-XII intact

MS/Ext No CCE Normal ROM Pigmented skin creases

on elbows Pedal pulses moderately

weak at 1+ Muscle strength 5/5

throughout

Peripheral Blood Smear Normochromic,

Normocytic erythrocytes

Laboratory Blood Test ResultsNa 126 meq/L Hct 33.2% Alk Phos 115 IU/L

K 5.2 meq/L RBC 4.1 million/mm3

Bilirubin 1.2 mg/dL

Cl 97 meq/L MCV 85 fL Protein 8.0 g/dL

HCO3 30 meq/L Plt 410,000/mm3

Albumin 4.7 g/dL

BUN 20 mg/dL WBC 6,800/mm3 Cholesterol 202 mg/dL

Cr 1.2 mg/dL • Neutros 49% Triglycerides 159 mg/dL

Glu 55 mg/dL • Lymphs 36% Fe 89 µg/dL

Ca 8.8 mg/dL • Monos 7% TSH 3.2 µU/mL

Phos 2.9 mg/dL • Eos 7% Free T4 16 pmol/L

Mg 2.9 mg/dL • Basos 1% Cortisol 2.0 µg/dL

Uric acid 3.6 mg/dL AST 33 IU/L ACTH 947 pg/mL

Hb 11.4 g/dL ALT 50 IU/L Vitamin B12 700 pg/mL

PE and Lab Tests cont. UA

Clear and yellow SG 1.016 pH 6.45 (-) blood

Imaging Abdominal CT scan

revealed moderate bilateral atrophy of the adrenal glands

Antibody Testing (+) 21-hydroxylase (-) 17-hydroxylase (-) C-P450

What is your diagnosis?

Rapid ACTH Stimulation Test

Condition Cortisol Assay Aldosterone Assay

Pre-cosyntropin 2.0 µg/dL 3.8 ng/dL

30 min post-cosyntropin

1.9 µg/dL 3.8 ng/dL

• Normal patient levels should double in 30 minutes• Diagnostic test to distinguish primary and secondary

adrenal insufficiency

Closing QuestionsWhat is the single greatest risk factor for

Addison disease in this patient?

What is the most likely cause of Addison disease in this patient?

Why can tuberculosis be ruled out as a cause of Addison disease in this patient?

Which two test results are most suggestive of the cause of Addison disease in this patient?

Closing QuestionsWould supplementation with fludrocortisone be

appropriate in this patient?

Does this patient have any signs of hypothyroidism, a disorder that is commonly associated with Addison disease?

There are 19 clinical signs and symptoms in this case study that are consistent with Addison disease. Identify 15 of them.

Which single test result is diagnostic for Addison disease in this patient?

Closing QuestionsWhich test results support the assessment that

the patient’s anemia is not the result of iron deficiency?

Which test results support the assessment that the patient’s anemia is not the result of vitamin B12 deficiency?

Why is shotty lymphadenopathy consistent with a diagnosis of Addison disease in this patient?