Case Report:
A 21-year-old man came to the emergency room, complaining of nausea and recurrent vomiting for the past two days after any oral intake. He was afebrile and didn’t recall eating something unusual. He also suffered for a month from malaise and dizziness when standing up. The dizziness improved while lying down. No loss of conscious, diarrhea or hematemesis was reported, but he had a history of BD. On examination, his blood pressure (BP) was low (60\40 mmHg) and had a tachycardia (117 beats/min). The patient reported normal appetite and denied weight loss. He had a history of BD which was diagnosed 4 years ago. At that time, he had arthralgia and the triad of BD, which was recurrent oral aphthous and genital ulcers, and iritis. He was treated with cyclosporine and naproxen and the patient decided to stop the treatment 18 months ago. He denied taking cortisol and his surgical history was insignificant. He had a family history of Crohn’s disease with his brother and rheumatoid arthritis with his sister. Hyperpigmentation was observed in the internal mucosa of the lips and gingiva (figure 1 ). Normal saline was infused and antiemetic was given intramuscularly. After stabilisation, his BP became 100\70 mmHg with normal heartbeats. His labs showed hyponatremia, mild hyperkalemia and normal glucose. ECG and chest x-ray were also normal. 8 AM cortisol was low with very high ACTH levels. Furthermore, TSH level was elevated, and TPO antibodies were positive. Thyroid ultrasonography showed a diffuse enlarged thyroid and radioactive iodine uptake test showed a low iodine uptake in the thyroid. This resulted in the diagnosis of HD. Anti TTG IgA was very high and duodenum biopsy showed stage 3a Marsh score which indicated CD.