Acute adrenal insufficiency after unilateral adrenalectomy in Cushing's syndrome: precipitation by lithium-induced thyrotoxicosis during cortisol replacement.
We present a patient with Cushing's syndrome due to adrenocortical adenoma who developed acute adrenal insufficiency one month after unilateral adrenalectomy. She had received lithium carbonate for five years for manic-depressive psychosis. Drug administration was interrupted for 2 weeks postoperatively and was resumed thereafter. At the adrenal crisis, her serum free T4 and T3 levels were both high and serum TSH was subnormal. The thyrotoxicosis subsided spontaneously within 2 weeks. Serum thyroglobulin was markedly increased during the thyrotoxic state. Tests for antimicrosomal antibodies and antithyroglobulin antibodies remained negative. Examination of an open-biopsy specimen of the thyroid gland showed no evidence of thyroiditis. We considered the transient thyrotoxicosis to be due to lithium-induced thyrotoxicosis. Caution should therefore be exercised in administering lithium carbonate, especially when the patient's adrenal reserve is low, since even a mild degree of thyrotoxicosis can precipitate an acute adrenal crisis.
Department of Internal Medicine, Kanazawa City Hospital, Japan.
Y
Y
Nagai
K
K
Ohsawa
T
T
Hayakawa
T
T
Abe
T
T
Sawada
K
K
Nakajima
Y
Y
Hashizume
K
K
Kobayashi
D000208:Acute Disease; D000309:Adrenal Insufficiency / Q000209:etiology*; D000315:Adrenalectomy / Q000009:adverse effects*; D000328:Adult; D003480:Cushing Syndrome / Q000601:surgery*; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use*; D016651:Lithium Carbonate / Q000009:adverse effects*; D013971:Thyrotoxicosis / Q000139:chemically induced / Q000150:complications / Q000188:drug therapy*
D016651:Lithium Carbonate; D006854:Hydrocortisone