Acute adrenal insufficiency (AI) is a life-threatening condition. While Addison's disease (AD) is rare, in developing countries, tuberculosis (TB) still remains as the primary cause in 7 to 20% of cases. Urinary TB is also the third most common form of extrapulmonary disease. We report a case of 37-year-old male who presented with weakness, anorexia, weight loss, dysuria, flank pain and low grade fever. Examination revealed hypotension, hyperpigmentation, hyponatremia, hypoglycemia and low serum cortisol. He was diagnosed to have adrenal crisis due to Addison's disease and extrapulmonary TB manifesting as urinary tract infection (UTI). He was treated with corticosteroids and anti-TB medications. Urologic reconstructive surgery was subsequently planned..

Objective. The implementation of guidelines in clinical practice is still facing a lot of obstacles. Although clinical recommendations of dyslipidemia are extant, little is known about how community physicians view guidelines and their implementation. The objective of this study is to assess the acceptance of guideline content and perceived implementation of dyslipidemia guidelines among physicians in Malang, Indonesia.Methodology. Semi-structured validated questionnaires were given to 67 random physicians consisting of general practitioners (GP), internal medicine residents and internists. The questionnaire consisted of 19 questions evaluating four parts: information about access to dyslipidemia training, dyslipidemia guideline-perceived knowledge, level of understanding of dyslipidemia guidelines and application rate of guideline adopted. Evaluation results were scored ordinally and divided into 3 levels; less, enough and good for each part of the questionnaire.Results. 89.2% of samples in the GP group lacked information about dyslipidemia training. The resident group had participated and were involved in dyslipidemia management training (98.3%), followed by the internist group (95.2%). In the GP group, 89.2% never or had less participation in dyslipidemia management training. The GP group (76.2%) also had had poor knowledge in understanding lipid guidelines, in which the least knowledge is known about targets of treatment, non-drug treatment and risk factors. Also, 40.3% of the GP group is still not capable of adopting dyslipidemia guidelines in daily practice. A major barrier was lack of understanding of guidelines (76.3%), followed by failure of adherence to the therapy of patients (12.1%). In the resident group, a major obstacle in the application of the guidelines is education level of the patient (45.5%). In all groups, HMG-CoA Reductase inhibitors are the most commonly used lipid-lowering drugs for treatment of dyslipidemia (98.1% in GP group, 96.3% in resident group, and 97.3% in internist group).Conclusions. GPs, as physicians in primary health care system, had poor information and participation in dyslipidemia training, and poor knowledge of dyslipidemia guidelines (AACE, AHA, CCS), as well as understanding and application of the dyslipidemia guidelines (ATP III, PERKENI) to the population, whereas residents and internists had better perception and application of dyslipidemia guidelines.

Ocular involvement in Anti Phospolipid Syndrome (APS) includes a broad spectrum of manifestations from the anterior and posterior segment or the presence of neuro-ophthalmologic features. A female, 29 years old, came to ER handled by ophthalmology department, with chief complaint left visual loss suddenly since 4 hours before admission. Investigations revealed stable vital signs, VOD 20/20, VOS 1/300, funduscopy showedpale and cherry red spot on left retina, OCT revealed hyperreflective of left inner retinal layer, IgG aCL 51.7 U/mL (50.8 U/mL in OPD 3 months later), and the other examinations were within normal limit. Patient was diagnosed with Central Retinal Artery Occlusion due toPrimary Antiphospolipid syndrome. She was performed occular massage and anterior chamber paracintesis procedure, and given O2 6-8 lpm NRBM, Timolol 0.5% eye drop left eye bid, acetazolamide 250 mg bid, Kalium Slow Release 1 tab qd, Levofloxacine eye drop 1 drop/hour post surgery. After the result of IgM aCL available, we added warfarin 2 mg qd and aspirin 320 mg qd. Patient was discharged 2 days later as visual acuity improved with VOD 20/20 and VOS 0.5/60. Key words: Central retina artery occlusion, primary anti phospolipid syndrome, anti cardiolipin antibody