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.