Recovery of adrenal function in a patient with confirmed Addison's disease.

UNLABELLED: Addison's disease is a condition characterised by immune-mediated destruction of the adrenal glands leading to a requirement of lifelong replacement therapy with mineralocorticoid and glucocorticoid. We present a case of a 53-year-old man who presented at the age of 37 years with nausea, fatigue and dizziness. He was found to have postural hypotension and buccal pigmentation. His presenting cortisol level was 43 nmol/l with no response to Synacthen testing. He made an excellent response to conventional replacement therapy with hydrocortisone and fludrocortisone and then remained well for 16 years. On registering with a new endocrinologist, his hydrocortisone dose was revised downwards and pre- and post-dose serum cortisol levels were assessed. His pre-dose cortisol was surprisingly elevated, and so his dose was further reduced. Subsequent Synacthen testing was normal and has remained so for further 12 months. He is now asymptomatic without glucocorticoid therapy, although he continues on fludrocortisone 50 µg daily. His adrenal antibodies are positive, although his ACTH and renin levels remain elevated after treatment. Addison's disease is generally deemed to lead to irreversible cell-mediated immune destruction of the adrenal glands. For this reason, patients receive detailed counselling and education on the need for lifelong replacement therapy. To our knowledge, this is the third reported case of spontaneous recovery of the adrenal axis in Addison's disease. Recovery may therefore be more common than previously appreciated, which may have major implications for the treatment and monitoring of this condition, and for the education given to patients at diagnosis. LEARNING POINTS: Partial recovery from Addison's disease is possible although uncommon.Patients with long-term endocrine conditions on replacement therapy still benefit from regular clinical and biochemical assessment, to revisit optimal management.As further reports of adrenal axis recovery emerge, this may influence the counselling given to patients with Addison's disease in the future.

Effects of conventional sucrose-based, fructose-based and isomalt-based chocolates on postprandial metabolism in non-insulin-dependent diabetics.

Milk chocolate is rich in both sucrose and fat, and is therefore considered unsuitable for diabetics. Nevertheless there is little information on the metabolic effects of conventional chocolate or specialized formulations with reduced sucrose content. In the present study six male non-insulin-dependent diabetes mellitus patients (age range 35-60 years; body-mass index less than 28) consumed test meals of chocolate (75 g) on three separate occasions. The control chocolate contained sucrose (45.5% w/w); the test chocolates contained either fructose (45.5% w/w) or isomalt (45.1% w/w). The latter is a sweet disaccharide alcohol which has no glycaemic effect when consumed as a pure compound. Venous blood samples were obtained at 30 min intervals for 5 h, and analysed for glucose, insulin, lactate and triglycerides. All three chocolates provoked a sustained rise in blood glucose, which reached a maximum at 90 min after ingestion and returned to baseline values by 5 h. The highest blood glucose levels occurred after conventional chocolate, and differences were statistically significant at 60 and 90 min (P less than 0.05). The area under the glycaemic curve for isomalt chocolate was 36% smaller than that for conventional chocolate (P less than 0.05), and there were differences in insulin and lactate levels, consistent with the lower glycaemic effect. The glycaemic response to the fructose-based chocolate was also lower than that to control chocolate but the difference was not significant. All three chocolates led to a similar sustained rise in serum triglyceride levels. Isomalt appears to be a palatable alternative sweetener capable of reducing the glycaemic effect of diabetic confectionary.