Differentials
Adrenal suppression due to the use of glucocorticoid or other drugs with glucocorticoid activity (e.g., medroxyprogesterone acetate therapy)
SIGNS / SYMPTOMS
History of long-term glucocorticoid or medroxyprogesterone acetate therapy. Recent dose alteration, abrupt discontinuation, noncompliance with medication, or concurrent infection.
May have Cushingoid appearance.
No hyperpigmentation.
INVESTIGATIONS
Low adrenocorticotropic hormone due to hypothalamic-pituitary-adrenal axis suppression.
Central (secondary or tertiary) adrenal insufficiency (pituitary or hypothalamic lesions)
SIGNS / SYMPTOMS
History of known pituitary or brain lesion; history of brain irradiation. Symptoms related to other hormonal deficiencies or excess.
INVESTIGATIONS
Low adrenocorticotropic hormone level.
Pituitary hormone abnormalities: thyroid-stimulating hormone, prolactin, follicle-stimulating hormone, luteinizing hormone, growth hormone.
CT or MRI brain showing lesion in the pituitary gland or hypothalamus.
Hemochromatosis
SIGNS / SYMPTOMS
Hyperpigmentation rarely involves mucosa.
INVESTIGATIONS
Transferrin saturation is increased (50% to 100%) and serum ferritin is substantially elevated (>900 to 6000 micrograms/L). Patients often have abnormal hepatic function.
Hyperthyroidism
SIGNS / SYMPTOMS
Tremor, nervousness, tachycardia.
Unexplained weight loss despite good appetite.
INVESTIGATIONS
Elevated triiodothyronine (T3) and free thyroxine (T4) levels.
Thyroid-stimulating hormone is suppressed.
Occult malignancy
SIGNS / SYMPTOMS
Varies with the malignancy type.
INVESTIGATIONS
Varies with the malignancy type.
Anorexia nervosa
SIGNS / SYMPTOMS
Fear of gaining weight, disturbed body image, weight loss, amenorrhea.
INVESTIGATIONS
Normal or elevated serum cortisol.
Low sex steroids, luteinizing hormone, and follicle-stimulating hormone.
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