A 44‐year‐old man presented to the emergency department with one month of worsening breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, and pitting oedema to the thighs. Past medical history included hypertension, dyslipidaemia, and tophaceous gout. His regular medications were perindopril, amlodipine, atorvastatin and frusemide. On examination, his blood pressure was 189/99 mmHg and oxygen saturation was 90% on room air. The patient had cushingoid features such as dorsocervical fat pad, livid abdominal striae, and moon facies. His investigations included chest x‐ray showing pulmonary congestion; transthoracic echocardiogram demonstrating diastolic dysfunction, with preserved ejection fraction of 55%; and normal urinary protein, with creatinine ratio and liver screens not suggestive of cirrhosis. Blood tests showed undetectable morning cortisol (< 10 nmol/L; reference interval [RI], 200–650 nmol/L), low adrenocorticotropic hormone (ACTH; < 5 ng/L; RI, 10–50 ng/L) and low urinary free cortisol (13 nmol/d; RI, 10–165– nmol/d). It was suspected the patient had secondary adrenal insufficiency from exogenous glucocorticoid use. However, both the general practitioner and the patient denied any recent glucocorticoid use.
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