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John K. Emy, M.D.
New York University Medical Center
New York, NY 10016
References
Beautiful she is, and bronzed, too, but not by the sun. The patient is the twin on the right, who appears older than her sister and gaunt in comparison — sequelae of chronic adrenocortical deficiency (Addison's disease). But what of etiology?
Were Dr. Frothingham an endocrinologist, we might perhaps guess that the patient's adrenocortical deficiency is idiopathic. But the doctor's publication record suggests that he is a mycobacteriologist. We believe, therefore, that the patient has tuberculosis, with adrenal involvement and secondary adrenal insufficiency.
Robert L. Deresiewicz, M.D.
Kevin M. Dushay, M.D.
Harvard Medical School
Boston, MA 02115
References
Does the blame lie deep within
That one twin looks dark and thin?
For sure there is no telling
Why her adrenal glands are failing.
Most likely, says the detective,
Autoimmunity made them defective.
Dietmar Schiller, M.D.
Elisabethinen Hospital
A-4010 Linz, Austria
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Damien Roos, M.D.
10, Quai du Canal
67700 Saverne, France
With regards from a devoted reader since my resident days more than 55 years ago.
Sir Richard Bayliss, M.D.
61 Onslow Sq.
London SW7 3LS, United Kingdom
To the Editor: The patient on the right (an old friend of mine) has adrenal insufficiency, probably caused by autoimmune adrenocortical disease. She had fatigue for at least one year. During the preceding three months she had nausea, vomiting, and dizziness and lost 13 kg. A medical evaluation revealed only asymptomatic cholelithiasis, and she was scheduled for elective cholecystectomy. After seeing her in church and noting her hyperpigmentation, I suspected that she had adrenal insufficiency and brought her to the hospital. Her blood pressure and pulse were 85/40 mm Hg and 84 per minute, respectively, while she was sitting and 78/28 mm Hg and 124 per minute while she was standing. The remainder of the examination was normal except for the hyperpigmentation. The results of laboratory studies were as follows: serum sodium, 130 mmol per liter; potassium, 4.4 mmol per liter; cortisol, 1.0 µg per deciliter (normal, 5–28 µg per deciliter) at base line and 0.7 µg per deciliter one hour after cosyntropin injection. All the patient's symptoms responded promptly to combined glucocorticoid and mineralocorticoid replacement therapy, and her pigmentation gradually returned to normal.
Both women have had recent physical examinations and laboratory studies. Both have normal thyroid function, but their mother has hypothyroidism. Both have normal serum glucose concentrations now, but the twin on the left had gestational diabetes during the last two of her seven pregnancies.
Both women have had stable facial weakness since birth. The twin on the left is left-handed and has right facial weakness. She has a slightly asymmetric smile and cannot wink her right eye. The twin on the right is right-handed and has left facial weakness to the same degree.
Richard Frothingham, M.D.
Durham Veterans Affairs Medical Center
Durham, NC 27705-3875
Jerome P. Kassirer, M.D.
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