Addisonian crisis in a young man with atypical anorexia nervosa

Background. A 22-year-old man was admitted to an intensive care unit with severe hyponatremia, hypotension and somnolence. He had a 9-month history of weight loss and vomiting that had led to a previous diagnosis of atypical anorexia, and he had been transferred from a psychiatric clinic. Investigations. Generalized hyperpigmentation and dehydration were noted on physical examination. Baseline concentrations of plasma adrenocorticotropic hormone, serum cortisol, plasma renin and serum aldosterone were analyzed. Determination of antibodies against adrenal steroid 21-hydroxylase, measurement of very-long-chain fatty acids and thyroid function tests were performed. Diagnosis. Primary adrenal insufficiency caused by isolated autoimmune adrenalitis and adrenal crisis. Management. Immediate administration of hydrocortisone (100 mg bolus dose followed by 100 mg over 24 h per continuous infusion) and physiological saline infusions (initially 4 l over 24 h). After stabilization, initiation of chronic hormone replacement therapy with hydrocortisone (initially 30 mg per day) and fludrocortisone (0.1 mg daily). The patient was instructed on how to adjust hydrocortisone doses in stressful situations and provided with an emergency card.