We present the case of a 21-year-old male patient, with no known allergies or other history, who came to the emergency department for a 6-month clinical picture of asthenia, increased fatigue with moderate exercise and accompanied by a general syndrome with a weight loss of about 10 kg during these months. Due to episodes of abdominal pain during this period, he visited the emergency department twice and underwent gastroscopy, reported as minimal hiatus hernia with grade I oesophagitis and duodeno-gastric bile reflux. In the last 5 days, his symptoms worsened, with vomiting, more intense diffuse abdominal pain and liquid stools with no increase in the number of stools.
Physical examination showed blood pressure of 120/60 mmHg, heart rate of 110 pm, afebrile, conscious and oriented, without neurological focality, eupneic, cardiac auscultation was rhythmic, tachycardic, without murmurs, the abdomen was soft and depressible, diffusely painful, without defence on palpation, no masses or megaliths were palpated. There was generalised skin hyperpigmentation, accentuated in the nipples, genital area and with melanic spots on the palate and gingival borders.
Blood tests on admission showed blood glucose 59 mg/dL, creatinine 4.32 mg/dL, urea 214 mg/dL, Na 123 mg/dL, K 8.0 mg/dL, Ca 8.2 mg/dL, arterial blood gas with pH 7.24, pCO2 35.6 mmHg, pO2 107 mmHg (with O2 at 4 litres/minute), bicarbonate 14.4 mmol/L, EB - 11.3 mmol/L and SatO2 97.2%. Haemoglobin 13.4 g/dl, haematocrit 39.5%, MCV 83 fL, leucocytes 12,800 (45% neutrophils, 32% lymphocytes, 12% monocytes and 10.5% eosinophils). Coagulation without alterations.
The electrocardiogram showed sinus tachycardia at 110 bpm with RSR' configuration and QT prolongation (487 ms). Chest X-ray was normal.
During his stay in the ED, measures were initiated to correct the hyperkalaemia but the patient became progressively sweatier, tachycardic and hypotensive (BP 85/46 mmHg) and, with the suspicion of an Addisonian crisis, admission to the ICU was decided and volume replacement with saline was initiated (4. 500 cc in the first 24 hours), glucose, actocortin (100 mg i.v. bolus followed by 400 mg in continuous intravenous infusion in the following 24 hours); initially requiring vasopressor amine perfusion (dopamine at 10 mcg/kg/min), which could be withdrawn in 36 hours.
Blood samples taken prior to the start of corticosteroid treatment to determine adrenal function showed a basal cortisol 4.0 mg/dL and plasma ACTH 264 pg/ml.
Determination of serum anti-adrenal capsule antibodies by indirect immunofluorescence was positive with a titre of 1/80.
The determination of thyrotropin, free thyroxine, FSH and LH, as well as anti-thyroglobulin and anti-microsomal peroxidase antibodies were within normal ranges.
Abdominal CT: presence of morphologically normal adrenal glands.
The patient was discharged from the Intensive Care Unit 3 days after admission and from the hospital 7 days later with renal function and ion parameters within normal range and with treatment with hydroaltresone 20 mg vo/8 h.