To the editor: The hematological manifestations of Addison's disease, including anemia, lymphocytosis, and eosinophilia, have been known for nearly eight decades [1]. We report a case of acute, profound neutropenia in a patient receiving therapeutic adrenal suppression. A 62-year-old woman presented to an outside institution with weakness, muscle cramps, and refractory hypertension. She was subsequently diagnosed with Cushing's syndrome, based upon an abnormal dexamethasone suppression test (cortisol 127 lg/dL, post-dexamethasone reference range <2 lg/dL, a.m. cortisol reference range 5-25 lg/dL) and elevated serum ACTH (262 pg/mL, reference range 20-100 pg/mL). Magnetic resonance and computerized tomographic imaging of the head, neck, chest, abdomen, and pelvis revealed bilateral adrenal hyperplasia but did not indicate an extrapituitary source of ACTH. The patient was subsequently transferred to our institution where she was noted to be hypertensive (blood pressure 145/81 torr) with fragile skin and a prominent nuchal fat pad. Laboratory evaluation revealed an elevated glucose (233 mg/dL) with normal serum electrolytes. A CBC was remarkable for a normochromic-normocytic anemia (Hb 7.9 g/dL), leukocytosis (12.4 3 10 3 / mmL with 94% neutrophils and 4% lymphocytes), and a normal platelet count (165 3 10 3 /mmL).The patient was started on an adrenal-suppressive regimen comprised of metyrapone (750 mg q6h) and ketoconazole (600 mg bid), effecting a threefold reduction in the serum cortisol level by hospital day 9 (see Fig. 1). On day 12, the patient displayed acute circulatory collapse (systolic blood pressure <70 torr) necessitating initiation of intravenous pressors. Thorough microbiological evaluation, including serial blood and urine cultures, did not reveal an infectious origin. Radiological studies were unchanged from baseline. An emergent blood count revealed severe leukocytopenia (1.1 3 10 3 / mmL with 64% lymphocytes and 4% neutrophils) and an absolute neutrophil count of 44/mmL. A Wright-stained peripheral smear revealed rare nucleated red-blood cells, granulocytopenia with normal cellular morphology, and adequate platelets. Interval decline in the serum cortisol level suggested a diagnosis of acute adrenal insufficiency. The metyrapone was immediately discontinued and the patient administered a single 100 mg dose of hydrocortisone ( Fig. 1, arrow). The patient exhibited rapid, parallel recoveries in serum cortisol, leukocyte count, and absolute granulocyte number, as well as rapid improvement in overall medical condition, and was transferred to the general ward service 2 days later.The acute neutropenia observed in this patient is remarkable both for its etiology as well as its severity. As hypocortisolism is commonly associated with both lymphocytosis [1] and eosinophilia [2], and can be accompanied by mild granulocytopenia [3,4], profound neutropenia as exhibited in the current case appears to be rare [5]. The possibility that the patient's granulocytopenia resulted from other, more common mechanisms,...
