A 62-year-old man was admitted to the emergency department with hypotension and altered consciousness. On physical examination, he had hyperpigmentation of the skin and mucous membranes. Admission tests revealed hypoglycemia, hyponatremia, and hyperkalemia. Fluid resuscitation was initiated with no improvement in blood pressure. Because adrenal crisis was suspected, blood samples for cortisol and adrenocorticotropic hormone were collected before commencing hydrocortisone, after which blood pressure improved and electrolyte disturbances disappeared. The tests revealed decreased serum cortisol and an increase in adrenocorticotropic hormone. A magnetic resonance imaging scan of the abdomen revealed evidence of bilateral adrenal hemorrhage. Positive antiphospholipid antibodies were detected during the investigations. This case underscores the importance of prompt evaluation of clinical signs and symptoms that may indicate adrenal crisis.

Background:One of the side effects of NSAIDs is hepatotoxicity or Drug-Induced Liver Injury (DILI). Despite the short course of NSAIDs, the patients with gout may develop DILI. At the same time, besides NSAIDs, there are additional factors that affect the functional state of the liver: demography, comorbidities or concomitant medication (1).Objectives:To determine comorbidities associated with the risk of DILI when taking NSAIDs during the attack of gouty arthritis.Methods:Our retrospective study included 200 patients with GA. Inclusion criteria for the study: presence of gout (ACR, 1977), initially normal serum ALT level, NSAIDs as anti-inflammatory drugs in gout. Exclusion criteria: presence of a known liver disease. All patients were divided into 2 groups: those who developed DILI (n = 86) and the control group without cytolysis during NSAID treatment (n = 114). The severity of the cytolytic syndrome was revealed as follows: mild form (2-3-fold excess of the ALT norm) in 81,4 % (n = 70); moderate (3-5 times higher ALT) in 15.1% (n = 13); severe (5-10 fold excess of ALT) in 3.4% (n = 3). The mean age of 55 (49-60) years and 54 (44-59.5) years as well as the sex distribution (men made 90.1% and 93.3%, respectively) were compatible in both groups (р>0,05). When studying the age distribution, statistical differences were revealed in the groups under 52 years (p<0,05), so, this parameter was included into logistic regression model. During the follow-up period, all patients took NSAIDs above average doses. Patients in both groups were comparable in duration of gout. The following parameters were compared: AH, IHD, diabetes mellitus, obesity, dyslipidemia, metabolic syndrome according to ATPIII, CKD, alcohol abuse, age under 52.Results:After conducting logistic regression analysis, the next comorbidities have been revealed to be statistically significant: obesity (OR – 2,15; 95%CI 1,16-3,98), dyslipidemia (OR – 3,41; 95% CI 1,56-7,44) and alcohol abuse (OR – 2,45; 95%CI 1,22-4,91). Worth to note that age under 52 was also a risk factor for DILI (OR – 2,14; 95%CI 1,13-4,04). Thus, among our patients, the younger ones with an unhealthy lifestyle and no serious comorbidities, including cardiovascular, were at a greater risk for developing DILI while taking NSAIDs during the gout attack.Conclusion:In the study group of patients with gout, the hepatotoxicity (cytolysis syndrome) risk due to NSAIDs intake increased in younger patients in the presence of signs of metabolic syndrome (obesity, dyslipidemia) and alcohol abuse.References:[1]European Association for the Study of the Liver. EASL Clinical Practice Guidelines Drug-induced liver injury. J. of Hepatology. 2019; 30: 1-40.Disclosure of Interests:None declared.