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16yo with back pain

This boy had Addison’s disease (adrenal insufficiency). Symptoms may include weakness, fatigue, dizzyness, anorexia, weight loss, salt craving. Signs include hyperpigmentation & freckling, particularly of skin folds, mucous membranes – this may precede other symptoms by months to years, and hypotension. On board exams often presented as an adolescent patient that has been diagnosed with anorexia nervosa and has a “good suntan.” The pictures shown here are from 2 weeks after diagnosis, and the hyperpigmentation has already improved quite a bit. Lab findings include hyponatremia, hyperkalemia, hypoglycemia, elevated LFTs, associated hypothyroidism, and eosinophilia. This patient had a very low random cortisol of 0.91 allowing the diagnosis to be made, but standard diagnosis is with an ACTH cosyntropin stim test. Replacement of glucocorticoids and mineralocorticoids is the treatment. Fluid refractory shock requires treatment with IV hydrocortisone.