Skin: Hyperpigmentation

Possiblity of opening statments
Look this lady who presented with weakness, loss of appetite and weight loss.

Suggested examination method
Hands-look at palmar creases for hyperpigmentation (Compare with your own palm)
Mouth-look at tongue, buccal mucosa for hyperpigmentation
Elbow: pressure points hyperpigmentation
Other sites: nipples, previous scars
Look for vitiligo

Tell examiner you would like to complete examination by:
checking her blood pressure (postural hypotension)
look for sparse axillary and puvic hair
Abdomen-?scars of previous bilateral adrenalectomy
Ask to check for visual field defect if you suspect Nelson's Syndrome.

Remember Nelson's syndrome is a enlarging pituitary tumour caused by previous bilateral adrenalectomy (done in the past for treatment of Cushing's Disease. Hyperpigmentation caused by high ACTH levels.)

Suggested presentation
"This young lady has generalized hyperpigmentation, which is more marked in the tongue and the palmar creases. The history suggest that she has Addison's disease. "

Questions you may be asked
(1) What are the causes of Addison's disease?
Idiopathic (80%)
TB (important to remember if you are taking exam in Singapore/Malaysia)
Metastasis
HIV infection

(2) How will you investigate this patient?
Biochemical tests to look for hypoNa, hyperK, metabolic acidosis
Blood glucose to look for hypoglycemia
I will do a screening test using the synacthen test to confirm the diagnosis.
I will also measure ACTH levels and cortisol levels.

Suggested reading for this topic
Polyglandular syndrome type I and II
Interpreting the synacthen tests.

Contributed by Lee Jun @ Giant Eagle @ Suikotsu (Sleeping Bone)

References:
250 cases in clinical medicine by Baliga
An Aid to the MRCP PACES by Ryder