A patient of tuberculosis presented with low levels of sodium, chloride and bicarbonate. He also had hyperpigmentation of palmar creases. Most probable diagnosis is: September2008

Ans. B: Addison's disease Primary adrenocoical deficiency (Addison's disease) More than 90% destruction is required to cause adrenal insufficiency. Autoimmune (-80% of cases) - Isolated adrenal insufficiency - Type I or II polyglandular autoimmune syndrome Infectious - Tuberculosis - Fungal Histoplasmosis Paracoccidioidomycosis Coccidioidomycosis Cryptococcosis HIV- or AIDS-related - HIV - Cytomegalovirus Mycobacterium avium-intracellulare infection Oppounistic fungal infection - Kaposi's sarcoma - Medication effect Metastatic invasion Bilateral adrenal hemorrhage - Associated with sepsis due to Pseudomonas infection or meningococcemia (Waterhouse-Friderichsen syndrome) - Anticoagulant therapy Adrenal infarction - Hypercoaguable states (antiphospholipid syndrome) Infiltrative Sarcoidosis - Amyloidosis - Hemochromatosis Hyperpigmentation may be striking/absent. It commonly appears on elbow/creases of the hand. In advanced stages of adrenal destruction, serum sodium, chloride and bicarbonate levels are reduced and the serum potassium levels is elevated. Hyperkalemia suggests primary adrenal insufficiency, because mineralocoicoid function is preserved in secondary adrenal insufficiency.