I was quite shocked by my patient Elaine’s appearance recently. Elaine’s case is definitely a skin problem that you do not often encounter in a private setting. “Miserable” is the best way to describe her. I can see a young woman in her early 30s just lying in bed and feeling depressed and hopeless compared to what was once an easygoing, cheerful soul according to her relatives.
Many people with chronic health problems don’t look sick. This is the case with Elaine, which is why she took it lightly when she was diagnosed with tuberculosis (through X-ray) last year. She was given medicines for this infection, which she stopped (without consulting her doctor) when she received the results of her sputum (saliva) exam, which turned out to be negative.
For many of us this is the way we live in general: most of the things that we value, we take for granted. We take families for granted, we take our jobs for granted, we take the freedom that we enjoy for granted. We live carelessly and with indifference towards the precious things that we assume will always be there, like health. So Elaine was no exception. This year was no different because she was diagnosed as HIV-positive (this could have been there earlier on), but she couldn’t care less. She never made any medical consult with regards to this, but just went on with her life.
It took a skin-color alteration for her to wake up and finally realize that she had taken her health for granted for too long a time. She is a typical girl who likes to do selfies and post on her Facebook account, but because of the remarkable horrible physical transformation she has to grapple with, this is all passé now. Elaine’s flawless white skin has turned into monstrous black ogre form, enhanced with fiery red eyes. This is accompanied by thickened skin with a lot of oozing fissures and scaling. She also has muscle weakness, chronic fatigue, weight loss, unproductive cough, and upon blood culture and sensitivity, was positive for Acinetobacter Baumanii, a bacterial infection.
My colleague prescribed her with Amikacin for this, but we were not able to do other tests anymore as Elaine was transferred to another hospital. What was prominent, however, with this patient is the physical appearance brought about by the sudden change in skin color, which does occur in some HIV patients secondary to the destruction of the adrenal glands (two endocrine glands that sit on top of the kidneys, producing a variety of hormones).
Each adrenal gland is composed of two distinct parts: the outer adrenal cortex and inner adrenal medulla. The adrenal glands secrete different hormones that act as chemical messengers. These hormones travel in the bloodstream and act on various body tissues to enable them to function correctly.
The adrenal cortex produces three hormones: Mineralocorticoids (aldosterone) a hormone that maintains the body’s salt and water levels, regulating blood pressure. Without aldosterone, the kidney loses excessive amounts of salt (sodium) and consequently, water, leading to severe dehydration and low blood pressure.
The hormone cortisol is involved in response to illness and helps regulate body metabolism. It stimulates glucose production by releasing necessary ingredients from storage (from fat and muscle) to make glucose. Cortisol also has significant anti-inflammatory effects.
Adrenal androgens like DHEA and testosterone play a role in the early development of the male sex organs in childhood, and female body hair during puberty. The adrenal medulla produces adrenaline, noradrenaline, and small amounts of dopamine — the hormones responsible for all the physiological characteristics of the stress response, the so-called “fight or flight” response when a person is provoked, as in being attacked in a fight.
I diagnosed Elaine as probably having primary adrenal insufficiency (Addison’s disease) based on her clinical manifestations. Several blood tests are needed to confirm my diagnosis, though.
Addison’s disease is one of the well-documented manifestations of HIV/AIDS-related endocrine disorders. Our patient could have multiple opportunistic infections (tuberculosis or more), which increase the risk of having a disorder in her adrenal glands. Unfortunately, she was transferred to another hospital before I could document the presence of other opportunistic infections as well.
She has a history of being treated with anti-tuberculosis drugs, which could also precipitate Addison’s disease, as a certain TB medication (rifampicin) can also lead to adrenal cortex disturbance, inducing adrenal insufficiency.
Addison’s disease results from bilateral destruction or dysfunction of the adrenal cortex. This disease has broad clinical features, from mild to life-threatening conditions.
The clinical features of Elaine are typical manifestations of Addison’s disease. The generalized hyperpigmentation is caused by increased production of pro-opiomelanocortin, a potent stimulator of melanin production.
Primary adrenal insufficiency is considered to be an incurable disease that needs lifelong glucocorticoid and mineralocorticoid replacement therapy. Primary adrenal insufficiency is an AIDS-related hormonal imbalance characterized by darkening of the entire skin, accompanied by muscle weakness, chronic fatigue, and reduction in body weight.
Some patients manifests with reduction in potassium, sodium, and blood sugar. This condition can also be induced by opportunistic infections such as tuberculosis, cytomegalovirus, HIV itself, and also antifungal therapy commonly used in HIV/AIDS patients.
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