Thyroxine Replacement and Acute Adrenal Crisis

Abstract

Letters to the EditorThyroxine Replacement and Acute Adrenal Crisis M. A. KhanMRCP M. A. Khan Department of Medicine King Abdul Aziz Hospital P.O. Box 245 Riyadh 11411, Saudi Arabia Search for more papers by this author Published Online::1 Sep 1988https://doi.org/10.5144/0256-4947.1988.390aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionA patient with hypothyroidism and subclinical panhypopituitarism in whom thyroxine replacement therapy precipitated secondary hypoadrenalism is described.A 65-year-old woman was seen elsewhere with clinical and biochemical evidence of hypothyroidism (low thyroxine; thyroid stimulating hormone [TSH] was not done as part of routine screening of thyroid function). Thyroxine was prescribed at a dose of 50 μg daily, and increased 2 weeks later to 100 μg, but she felt unwell and stopped taking the medication after 4 weeks.Six months later, she presented to the emergency room with acute confusional state and physical deterioration. Blood was taken for biochemical analyses including thyroxine, TSH, and Cortisol levels. A clinical diagnosis of myxedema madness was made, and a regimen of 50 μg of thyroxine daily was prescribed, which was increased to 100 μg after 5 days. There was no improvement in her condition, and she became hypotensive and hyponatremic; therefore, hypoadrenalism was suspected. She was given hydrocortisone intravenously which resulted in rapid improvement of her physical and mental state, hypotension, and hyponatremia.Results of investigation showed low serum free thyroxine, low TSH, and low cortisol, suggestive of pituitary insufficiency, thyrotropin-releasing hormone test, insulin tolerance test for growth hormone, and low Cortisol confirmed the diagnosis of pituitary insufficiency. Computerized tomography of the brain showed no pituitary tumor.This patient with panhypopituitarism in whom secondary hypoadrenalism became clinically manifest when thyroxine was given highlights the importance of considering other coexisting underlying conditions in patients with unfavorable response to treatment with thyroxine in hypothyroidism.Editor's note: This letter draws attention to the fact that patients with panhypopituitarism can develop addisonian (adrenal) crisis if replacement therapy with Cortisol does not precede thyroxine. Previous article Next article FiguresReferencesRelatedDetails Volume 8, Issue 5September 1988 Metrics History Published online1 September 1988 InformationCopyright © 1988, Annals of Saudi MedicinePDF download