Intended for healthcare professionals

Endgames Case Review

Tiredness in a patient treated with itraconazole

BMJ 2017; 356 doi: (Published 26 January 2017) Cite this as: BMJ 2017;356:i6819
  1. Preethi Nalla, specialist registrar in diabetes and endocrinology1,
  2. Thomas Alexander Dacruz, specialist registrar in diabetes endocrinology1,
  3. Kofi Obuobie, consultant in diabetes and endocrinology2
  1. 1University Hospital of Wales, Cardiff, Wales, UK
  2. 2Royal Gwent Hospital, Newport, Wales, UK
  1. Correspondence to preethin_nalla{at}

A 72 year old woman with allergic bronchopulmonary aspergillosis and asthma presented to the emergency department with a two week history of increasing tiredness and shortness of breath. She had no headache, visual disturbance, abdominal pain, nausea, vomiting, or collapse. Her medication included Seretide 250 Evohaler (fluticasone 250 µg and salmeterol 25 µg) one puff twice daily for four years and inhaled Salbutamol. She had been treated with itraconazole 200 mg daily for two years, after unsuccessful attempts to stop this medication due to recurrence of the disease. She had never required treatment with oral corticosteroids. There was no family history of autoimmune disorders.

Observations were stable on admission, specifically no postural hypotension. General physical examination was unremarkable. There was no hyperpigmentation, visual field defects, or clinical features of Cushing’s syndrome.

Full blood count, serum glucose, renal, and liver function tests were within normal limits. Random serum cortisol (1300 hours) was 4 nmol/L (9 am cortisol range, 138-635). Pituitary profile tests including TSH, FSH, LH, prolactin, and IGF-1 were within normal limits for the patient’s age. Adrenocorticotrophic hormone was less than 10 ng/L (7-51) and adrenal autoantibodies were negative. Chest radiograph and magnetic resonance imaging of pituitary showed no abnormal findings.


  • 1. What is the most likely diagnosis based on the hormone profile?

  • 2. What is the likely cause of the diagnosis in this case?

  • 3. How would you manage and follow up with this patient?

1. What is the most likely diagnosis based on the hormone profile?

Short answer

The hormone profile indicates secondary adrenal insufficiency. This explains the symptoms of tiredness and shortness of breath coupled with a very low serum cortisol (4 mmol/L) and a supressed adrenocorticotrophic hormone level.


This patient presented with non-specific symptoms and the clinical examination was entirely normal. The random cortisol levels were barely detectable, with suppressed adrenocorticotrophic hormone levels consistent with secondary adrenal insufficiency. The other …

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