Addison s Disease: A Case Report in Primary Care

Case Report

J Fam Med. 2021; 8(8): 1274.

Addison’s Disease: A Case Report in Primary Care

Tham CSW¹ and Sim SZ²*

1Ministry of Health Holdings, Singapore

2Clinical Research Unit, National Healthcare Group Polyclinics, Singapore

*Corresponding author: Sim Sai Zhen, Clinical Research Unit, National Healthcare Group Polyclinics, 3 Fusionopolis Link, Nexus@one-north, South Tower, # 05-10, Singapore

Received: September 16, 2021; Accepted: October 11, 2021; Published: October 18, 2021


Addison’s disease is a rare endocrine condition. This is a case report of a patient with Addison’s disease, who presented at a Singaporean primary care clinic with non-specific complaints of fatigue, reduced effort tolerance, hyperpigmentation of skin and features of depression. This case emphasizes the need for a broad approach to the undifferentiated symptoms in the primary care setting. It highlights clinical pearls relevant to any consult-a thorough consideration of the patient’s presenting complaint coupled with a perceptive physical examination, alongside considerations of using mobile technology and evidence based information to augment our daily practice.

Keywords: Addison’s Disease; Endocrine; Primary Care

Case Presentation

Patient A, a 58-year-old Indian lady, presented with 2 weeks of generalized lethargy, low mood as well as non-specific exertional dyspnea with reduced effort tolerance. This was the first time she had experienced such symptoms. She later offered a history of hyperpigmentation of her face, which bothered her significantly and contributed to her low mood. Over the past two years, she had noticed gradual darkening of her face and lips. This was corroborated with photographic evidence showing stark darkening of her face in the last 10 months. The facial hyperpigmentation was not pruritic or painful. There was no new drug usage, change in her facial products, or increased sun exposure. She had undergone five courses of laser treatment at an aesthetic clinic to treat her hyperpigmentation but saw no improvement.

She was frustrated and upset with the hyperpigmentation and her lethargy. Prior to the onset of her symptoms, she had been a fit individual with no significant health concerns. Her PHQ-9 score indicated moderately severe depression (score of 17) with persistent anhedonia, fatigue, poor appetite, insomnia, and psychomotor retardation.

The patient also had pre-existing type II diabetes mellitus and hyperlipidemia, and was taking Metformin 250mg BD. She also had an adrenal incidentaloma for which she was on follow up with an endocrine clinic. 4 months prior to her presentation, she had undergone a 24-hour dexamethasone suppression test, which was appropriately suppressed. Besides this, her past medical history was not significant for any known neuropsychiatric diseases, nor did she have any known cardiovascular, respiratory, renal issues or endocrinological issues that could explain the new symptoms.

On physical examination, the patient was alert, not cachectic and her mucous membranes were moist. Her initial vitals were as followed: blood pressure 106/59mmHg and heart rate 117 beats per minute. On repeated measurement, her blood pressure dropped to 90/52mmHg, and her heart rate was 100 beats per minute. There was hyperpigmentation of her face, vermillion border of her lips and palmar creases of both hands. Longitudinal melanonychia were seen in the index and middle finger nails of both hands. There was no pallor, lymphadenopathy, neck swelling or goiter. She appeared weak and had proximal myopathy with some difficulty standing up from a seated position. However, there was no hyporeflexia of the upper or lower limbs. The remaining physical examination of the cardiovascular, respiratory and abdominal systems were unremarkable.

Laboratory investigations in the clinic showed hyponatremia with hyperkalemia (Table 1). In view of her symptoms, physical signs and investigation results, a preliminary diagnosis of Addison’s disease to rule out Addisonian crisis was made and she was promptly referred to a tertiary hospital Accident and Emergency Department where she was admitted and initiated on hydrocortisone treatment. Six weeks later, she returned to the primary care clinic for routine review of her diabetes. Following successful treatment, her blood pressure had normalized, her lethargy, dyspnea and mood had improved and the hyperpigmentation had started to resolve.

Citation:Tham CSW and Sim SZ. Addison’s Disease: A Case Report in Primary Care. J Fam Med. 2021; 8(8): 1274.