Po83 "when Fatigue Is Not From Ageing, Nor The Tan From The Sun. . . "

Ana Catarina Marques1, Isabel Santos2, Carla Pereira1 e Lara Machado3
1USF Fafe Sentinela; 2UCSP Infias; 3USF Novo Cuidar
Background: Addison’s Disease (AD), or Primary Adrenal Insufficiency, is a rare condition (0.8 / 100 000). It is caused by the progressive destruction of adrenal cortex; idiopathic in 80% of cases. The consequent deficiency of glucocorticoids and mineralocorticoids is responsible for the symptoms of fatigue, asthenia, anorexia, and hypotension. The high levels of adrenocorticotropic hormone cause hyperpigmented skin by cross-reaction with melanin receptors. The identification and orientation of these patients are essential to prevent metabolic and ionic decompensation that can be lethal long term.
Case description: We report the case of MRN, male, 77 years old, Caucasian. Lives with his wife; a family in Duvall Family Cycle stage VIII and social middle-class in the Graffar scale. As medical background, he has epilepsy, medicated with valproic acid, 500mg, 2id. In September 2013, he requested a medical consultation with his Family Doctor (FD), due to marked fatigue and asthenia which motivated the use of a cane to aid his march. These symptoms have worsened in the past 2 years, and are accompanied by nausea and anorexia, with weight loss of 18 kg. At objective examination he presented hypotension (82 / 56 mmHg) and hyperpigmented skin, more pronounced on face and trunk, extending to palmar creases. His wife stated that the tan was unusual, with onset 2 years ago. Haemogram, ionogram, liver and kidney function, endoscopy and colonoscopy were requested. At the following consultation, he maintained the symptoms. The tests revealed hyponatriaemia (Na+=128mEq/L), hyperkalemia (K+=7.2mEq/L) and elevated creatinine 1.59mg/dL (35.77mL/min of creatinine clearance), with no other anomalies. He was referred to Emergency Room, explaining the clinical context and, attending to the characteristic clinical features, considering the diagnosis of primary adrenal insufficiency. The patient was admitted at the hospital, where the diagnosis of AD was confirmed.
Discussion: In AD, fatigue has a progressive onset, and the clinical features can have years of evolution. The onset of skin hyperpigmentation, in a characteristic tanned appearance, especially without association to sun exposure, should alert the clinician to the existence of this condition. FDs, by accompanying their patients over time, are in unique positions to detect these insidious changes and interpose a timely guidance.
Addison’s disease, fatigue, hyperpigmentation