A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.
On examination, his blood pressure was 100/60 mmHg.
Investigations:
serum sodium136 mmol/L (137-144)
serum potassium4.8 mmol/L (3.5-4.9)
short tetracosactide (Synacthen@) test (250 micrograms):
baseline serum cortisol100 nmol/L
serum cortisol (30 min after tetracosactide)250 nmol/L (>550)
anti-adrenal antibodiesnegative
What is the most important diagnosis to consider?

• A. autoimmune hypoadrenalism
• B. isolated adrenocorticotropic hormone deficiency
• C. adrenoleucodystrophy
• D. tuberculosis
• E. familial glucocorticoid resistance

An 80-year-old man was referred because of weight gain and low mood but said he was otherwise well. He had a complex cardiac history including a ventricular fibrillation arrest and a permanent pacemaker, but he had been very well for the past 3 years. He was taking amiodarone 100 mg daily, lisinopril 40 mg daily and furosemide 80 mg daily.
On examination, he had a pacemaker in situ and his pulse was 84 beats per minute and regular. He had a 2/6 mid-systolic murmur in the aortic area with no radiation, mild ankle oedema, and scanty basal crackles bilaterally on auscultation of his chest.
Investigations (before attending clinic):
serum thyroid-stimulating hormone19.0 mU/L (0.4-5.0)
serum free T411.0 pmol/L (10.0-22.0)
anti-thyroid peroxidase antibodies300 IU/mL (<50)
What is the most appropriate next step in management?

• A. start levothyroxine 25 micrograms daily
• B. stop amiodarone
• C. review with repeat thyroid tests in 3 months
• D. start liothyronine sodium 10 micrograms twice daily
• E. start levothyroxine 100 micrograms daily

A 26-year-old woman with previously well-controlled primary hypothyroidism had been an in patient for treatment of an eating disorder for the previous 6 weeks. She had a history of anaemia resulting from multiple vitamin deficiency and gastric erosions. She had been taking levothyroxine 125 micrograms daily for the previous 5 years; since admission her medication had also included ferrous sulfate, calcium and vitamin D, and sucralfate. Her daily medicines were taken under supervision at 09.00 h. Although she was eating better and had gained 4 kg in weight, she was now complaining of tiredness and feeling "worse than ever".
On examination, she was thin, slightly pale and had no palpable goitre. Recent blood tests had confirmed that her anaemia had resolved.
Investigations:
serum corrected calcium2.28 mmo/L (2.20-2.60)
serum thryoid-stimulating hormone12.0 mU/L (0.4-5.0)
serum free T48.0 pmol/L (10.0-22.0)
serum T30.90 nmol/L (1.07-3.18)
What is the most appropriate next step in management?

• A. no change in treatment
• B. add liothyronine 20 micrograms daily
• C. increase levothyroxine to 175 micrograms daily
• D. administer levothyroxine alone at bedtime
• E. stop treatment with calcium and vitamin D

A 58-year-old man was referred to the endocrine clinic after a CT scan of abdomen had shown a 4.5-cm left adrenal mass, with a Hounsfield unit measurement of 11 (consistent with high lipid content). He had a 10-year history of type 2 diabetes mellitus and was taking metformin. He was also taking atenolol for hypertension.
On examination at the clinic, his blood pressure was 162/94 mmHg. He was centrally obese with a body mass index of 27 kg/m2 (18-25).
Investigations:
serum potassium3.9 mmol/L (3.5-4.9)
plasma renin activity (after 30 min upright)1.0 pmol/mL/h (3.0-4.3)
plasma aldosterone (after 4 h upright)680 pmol/L (330-830)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol164 nmol/L (<50)
24-h urinary free cortisol132 nmol (55-250)
24-h urinary catecholamines
(adrenaline and noradrenaline)normal
As the lesion was >4 cm in diameter, laparoscopic adrenalectomy was recommended.
What is the most appropriate advice to give to the surgical team about perioperative
management?

• A. give corticosteroid cover during and after surgery and reassess postoperatively
• B. measure cortisol and aldosterone 2 weeks postoperatively
• C. give preoperative ?-adrenergic receptor blockade in case the lesion is an occult phaeochromocytoma
• D. short tetracosactide (Synacthen@) test 48 h postoperatively
• E. no special precautions are required