Clinical Case of Primary Adrenal Insufficiency: Diagnostic Difficulties, Therapeutic Tactics

Tuberculous adrenal insufficiency is a rare cause of primary adrenal insufficiency (PAI), characterized by insufficient production of glucocorticoids, mineralocorticoids, and androgens. Nonspecific symptoms of PAI complicate timely diagnosis and treatment, which often leads to a life-threatening condition, Addisonian crisis. This article presents a clinical observation of a 67-year-old female patient. For 8 months, the patient noted a gradual increase in general weakness, and decreased appetite. When visiting a local clinic in June 2022, she was diagnosed with irritable bowel syndrome. Condition on admission in the medical ward in October 2022 was manifested as severe general weakness, abdominal pain, muscle pain, nausea, vomiting. Given the above symptoms, Addisonian crisis was suspected. Before the results of diagnostic tests were obtained, the patient was given hydrocortisone 100 mg intravenously by jet stream 4 times per day. Based on the test results, the patient was diagnosed with primary adrenal insufficiency caused by a tuberculosis process. The patient was prescribed hormone replacement therapy, she was advised on the principles of independently adjusting the hormone therapy; a consultation with a TB specialist was also recommended to decide on initiating anti-tuberculosis therapy. The patient developed an Addisonian crisis due to a combination of factors: the treatment (the drug interaction), the impact of diagnostic procedures (bronchoscopy) and due to no correction of the prescribed hormone replacement therapy. After the acute condition was relieved, the patient was re-consulted by the endocrinologist who decided to increase the dosage of hormone replacement therapy and continue the treatment with antitubercular agents. This clinical case has demonstrated the specifics of diagnostics and selection of replacement therapy in the treatment of PNI. It has also shown that doctors of various specialties have to be better informed about the algorithm and tactics of managing patients with symptoms of Addisonian crisis.