Cardiac structural and functional abnormalities in primary hyperparathyroidism.

PURPOSE: Studies on cardiac structural and functional abnormalities in primary hyperparathyroidism (PHPT) have yielded conflicting and inconsistent results. In this prospective case-control study, we sought to compare cardiac structure and function in symptomatic PHPT patients and controls. METHODS: One hundred consecutive symptomatic PHPT patients and 113 matched controls underwent echocardiographic evaluation by the same operator. RESULTS: Left ventricular mass index (LVMI) was significantly higher in patients as compared to controls, (median of 90.95 g/m2 vs 86.5 g/m2, p = 0.041). Patients had significantly lower early trans-mitral diastolic flow (E velocity) as compared to controls (57.13 ± 14.88 vs 64.76 ± 15.45 cm/s, p < 0.001). Patients also had significantly lower early to late mitral annular velocity (E/A) as compared to controls (0.98 ± 0.37 vs 1.10 ± 0.34, p 0.013). Patients had higher frequency of aortic valve calcification (29% vs 2.65%, p < 0.001), mitral annular calcification (23% vs. 4.42%, p < 0.001), myocardial and septal calcifications (25% vs none, p < 0.001) as compared to controls. Serum PTH, calcium and uric acid significantly correlated with calcifications. Serum calcium showed a negative correlation with E/A ratio. CONCLUSIONS: Symptomatic patients with PHPT have substantial cardiac structural and functional abnormalities. These abnormalities include elevated LVMI, diastolic dysfunction, and aortic valve, mitral annular, septal and myocardial calcifications. We strongly suggest and conclude that the evaluation of PHPT patients should not only include traditional end organs like bones and kidneys but also the cardiovascular system in the form of echocardiography to detect subclinical cardiac dysfunction so that the cardiovascular health of such patients can be optimized.

Primary hyperparathyroidism and pancreatitis.

PURPOSE: The true association between primary hyperparathyroidism (PHPT) and pancreatitis continues to be controversial. In this study, we present clinical data, investigative profile, management and follow-up of PHPT patients with pancreatitis and compare this group with PHPT patients without pancreatitis. METHODS: Records of 242 patients with PHPT managed at our center over 24 years were retrospectively analyzed for demographic and laboratory data. The diagnosis of pancreatitis was entertained in the presence of at least two of the three following features: abdominal pain, levels of serum amylase greater than three times the normal or characteristic features at imaging. RESULTS: Fifteen (6.19%) of the 242 consecutive patients with PHPT had had pancreatitis. Fourteen patients (93.3%) had acute pancreatitis (AP), while one patient had chronic calcific pancreatitis. Over half (8 of 14) of the patients with AP had at least two episodes of pancreatitis. Pancreatitis was the presenting symptom in 14 (93.3%) patients. None of the pancreatitis cases had additional risk factors for pancreatitis. PHPT patients with pancreatitis had significantly higher serum calcium and ALP than PHPT patients without pancreatitis. After successful parathyroidectomy, 14 patients had no further attacks of pancreatitis during a median follow-up of 16 months (range 2-41 months), while recurrence of pancreatitis was seen in one patient. CONCLUSIONS: We conclude that pancreatitis can be the only presenting complaint of PHPT. Our study highlights the importance of fully investigating for PHPT in any pancreatitis patient with high normal or raised serum calcium level, especially in the absence of other common causes of pancreatitis.

Causes of mortality in diabetes mellitus: data from a tertiary teaching hospital in India.

BACKGROUND: Mortality studies can show the relative contribution of diabetes to mortality in the total population, and they can provide important descriptions of the changes in causes and frequency of diabetes mortality over time. OBJECTIVE: To find the mortality pattern in people with diabetes admitted to a tertiary care hospital in a developing country, using underlying/contributory causes of death. METHODS: In this retrospective study, mortality trends among people with diabetes admitted to Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India were reviewed by screening the hospital records of all people with diabetes who died over the last 9 years, carrying forward earlier observations from the same centre. RESULTS: Of 234 776 people admitted to the centre during the review period, 16 690 (7.11%) died; 741 (383 men) of these had diabetes mellitus mentioned on the death certificate. The mean (SD) age at death for people with diabetes was 60.07 (13.62) years in men and 57.36 (13.40) years in women. The leading contributory causes of death were infections (40.9%), chronic renal failure (33.6%), coronary artery disease (16.9%), cerebrovascular disease (13.2%), chronic obstructive pulmonary disease (6.9%), acute renal failure (6.2%), malignancy (4.2%), hypoglycaemia (3.5%) and diabetic ketoacidosis (3.4%). The cause of death could not be ascertained in 2.8% of cases; in 52.9%, 36.3% and 8.0% cases one, two and three or more causes, respectively, were recorded as the cause of death. CONCLUSIONS: The aetiological spectrum of mortality in people with diabetes at this Indian centre continues to be dominated by infections and renal failure, which is different from that in the developed world, where coronary artery disease and cerebrovascular disease are the principal causes of death in people with diabetes.

Vitamin D status in apparently healthy adults in Kashmir Valley of Indian subcontinent.

BACKGROUND: The worldwide prevalence of vitamin D deficiency is reported to be high. OBJECTIVES: To assess the vitamin D status in apparently healthy adults in Kashmir valley by measuring serum 25-hydroxyvitamin D (25 (OH) D). METHODS: 92 healthy natives (64 men and 28 non-pregnant/non-lactating women, aged 18-40 years), residing in Kashmir for at least last 5 years and not having any suggestion of systemic disease, were selected for this study. The samples were collected throughout the year in both summer and winter months. Vitamin D deficiency was defined as a serum 25 (OH) D concentration of <50 nmol/l and graded as mild (25-50 nmol/l), moderate (12.5-25 nmol/l) and severe (<12.5 nmol/l). RESULTS: Body mass index, total energy intake, and other nutritional parameters were comparable among subjects in different groups. Overall 76 (83%) of the subjects studied had vitamin D deficiency--25%, 33%, and 25% had mild, moderate, and severe deficiency, respectively. 49 of the 64 males and all but 1 of the 28 females were vitamin D deficient. The prevalence of vitamin D deficiency ranged from 69.6% in the employed group to 100% in the household group. Vitamin D deficiency was equally prevalent in subjects from rural and urban areas. Serum calcium and phosphorus values were comparable in subjects with and without vitamin D deficiency, while daily intake and urinary excretion of calcium were significantly lower in the former. Vitamin D deficient subjects had a significantly lower mean weekly exposure to sunlight. CONCLUSIONS: In spite of abundant sunlight, healthy individuals in Kashmir valley are vitamin D deficient, particularly women. Serum 25 (OH) D concentrations are significantly related to sun exposure.

Amelogenesis Imperfecta with Distal Renal Tubular Acidosis: A Novel Syndrome?

Amelogenesis imperfecta (AI) is a heterogeneous group of inherited dental enamel defects. It has rarely been reported in association with multiorgan syndromes and metabolic disorders. The metabolic disorders that have been reported in association with AI include hypocalciuria, impaired urinary concentrating ability, and Bartter-like syndrome. In literature, only three cases of AI and distal renal tubular acidosis (dRTA) have been described: two cases in adults and a solitary case in the pediatric age group. Here, we report a child with AI presenting with dRTA; to the best of our knowledge, our reported case is the only second such case in pediatric age group. Our case highlights the importance of recognizing the possibility of renal abnormalities in patients with AI as it will affect the long-term prognosis.

Clinical and etiological profile of hyperprolactinemia--data from a tertiary care centre.

OBJECTIVE: To study the clinical presentation and etiology of hyperprolactinemia, a common disorder encountered in endocrine practice. METHODS: We analyzed the clinical data, hormone profile and imaging reports of 187 females with documented hyperprolactinemia, over a period of 6 years (5 years retrospective analysis and one year prospective study). RESULTS: Majority of the 187 subjects studied presented in 3rd or 4th decade. Galactorrhoea was the commonest presenting symptom occurring in 159 subjects (85%), followed by amenorrhea in 68.9%; both amenorrhea and galactorrhea were seen in 45.4%. A microprolactinoma was demonstrated in 67 patients (35.8%), a nonfunctioning pituitary macroadenoma with stalk hyperprolactinemia occurred in 30 patients (16%) and polycystic ovarian disease was documented in 24 (12.8%). In 52 patients (27.8%) no apparent cause could be ascertained. CONCLUSIONS: Syndrome of amenorrhea and/or galactorrhea is the commonest presentation in hyperprolactinemia. Microprolactinoma was the most frequent identifiable etiology followed by idiopathic and stalk hyperprolactinemia in our series.

Epidemiologic and etiologic aspects of primary infertility in the Kashmir region of India.

OBJECTIVE: To assess the magnitude of primary infertility and to study its etiologic aspects in India. DESIGN: After proper randomization, 10,063 married couples were interviewed to ascertain the prevalence of primary infertility. A definitive protocol was followed to determine the etiology of primary infertility in 250 consecutive couples. SETTING: Tertiary care medical center in the Kashmir valley of India. PATIENT(S): Couples married for > or = 1 year; 250 consecutive couples attending an endocrine clinic for primary infertility. INTERVENTION(S): A logical investigative protocol was followed to identify the etiology of infertility. MAIN OUTCOME MEASURE(S): Magnitude of primary infertility in the community as well as the male, female, or combined etiology of infertility. RESULT(S): Fifteen percent of the couples interviewed had primary infertility, among whom 4.66% had unresolved infertility at the time of the survey. The etiology of infertility in 250 consecutive couples revealed a female factor in 57.6%, a male factor in 22.4%, combined factors in 5.2%, and an undetermined cause in 14.8%. CONCLUSION(S): Primary infertility is as common and distressing a problem in India as in other parts of the world. Semen abnormalities (22.4%), anovulation (17.2%), ovarian failure (8.8%), hyperprolactinemia (8.4%) and tubal disease (7.2%) are common causes of infertility. The pattern of infertility in India is the same as in other parts of the world, except that infertile couples report late for evaluation.

Mortality in diabetes mellitus--data from a developing region of the world.

This retrospective study presents the mortality trends in diabetic patients in a developing region of the world. The data were collected by screening the hospital records of all diabetic patients who died over a period of a decade at Institute of Medical Sciences, a tertiary care medical centre in Kashmir Valley of India. Of 133,374 patients admitted to the centre from January 1987 to December 1996, 9627 died, of whom 269 (151 males and 118 females) were recorded to have diabetes mellitus. The mean+/-S.D. age at the time of death was 51.61+/-13.77 years for males and 51.50+/-15.50 years for females. The common causes contributing to death were infections (33.83%), chronic renal failure (30.85%), coronary artery disease (16.36%), cerebrovascular disease (13.75%), hypoglycaemia (7.81%), diabetic ketoacidosis (6.69%) and hyperosmolar coma (2.23%). In 7.43% patients the cause of death could not be ascertained. Death was attributed to single cause in 60.22%, to two causes in 26.39% and to three or more causes in 5.95%. Most (59.11%) of these diabetic patients died within a week of hospitalisation. We conclude that mortality trends in diabetes mellitus differ in developing regions as compared to developed regions reflecting poor healthcare in general and diabetic care in particular. Unlike in west, where the major killers in diabetic patients are coronary artery disease and cerebrovascular disease, infections and chronic renal failure continue to be leading causes of death in patients with diabetes mellitus in developing regions like ours.

Prevalence of type 2 diabetes mellitus and impaired glucose tolerance in the Kashmir Valley of the Indian subcontinent.

This cross-sectional population survey was undertaken to determine the prevalence of type 2 diabetes and impaired glucose tolerance in subjects aged 40 years or more in Kashmir Valley, India. The study was carried out in two phases. In phase one, 6091 randomly selected subjects, 40 years or older, from all six districts of the valley were surveyed for prevalence of known diabetes mellitus. In phase two, 5083 subjects, 40 years or older, were screened with oral glucose tolerance test for prevalence of undiagnosed (asymptomatic) diabetes mellitus and impaired glucose tolerance. Abnormalities of carbohydrate intolerance were determined as recommended by WHO. Of 6091 subjects interviewed, 115 were known cases of diabetes mellitus with an overall prevalence of 1.89% (1.98% in males and 1.77% in females). Results of glucose tolerance test revealed that mean fasting as well as mean 2 h blood glucose was significantly more in females as compared to males (4.68+/-0.91 and 6.40+/-2.12 vs. 4.49+/-0.96 and 5.94+/-2.03 mmol/l, respectively, P < 0.0001). Of 5083 subjects who were subjected to glucose tolerance test (GTT), 627 (12.34%) had an abnormal test; with 411 (8.09%) having impaired glucose tolerance (IGT) and 216 (4.25%) having diabetes mellitus. The prevalence of IGT as well as of diabetes was significantly more in females as compared to males (P < 0.001). Subjects who had family history of diabetes had a significantly higher prevalence of abnormal GTT. Prevalence of known diabetes as well as that of abnormal GTT steadily increased with age, with a highest prevalence in the age group of > or = 70 years (P < 0.001). Obese subjects had a significantly higher basal as well as 2 h blood glucose in males as well as in females. Subjects with diabetes on GTT had a higher waist/hip ratio. Overall the prevalence of diabetes as well as IGT was significantly higher in the urban population. We conclude that 1.89% of the general population have known diabetes, 4.25% have undiagnosed diabetes and 8.09% have impaired glucose tolerance test; making the total load of abnormal glucose tolerance 14.23% in Kashmir Valley. In subjects greater than 40 years of age having a family history of diabetes, obesity, higher age (50 years or above), female sex, and urban origin have more chance (odds ratio: 4.65, 2.30, 1.87, 1.49 and 1.16, respectively) of developing abnormal glucose tolerance.

Impaired fasting glucose and impaired glucose tolerance - lack of agreement between the two categories in a North Indian population.

This study was carried out to determine the relationship between impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) in a North Indian population. The data in 5083 subjects studied earlier was reanalyzed by applying new WHO diagnostic criteria. Reanalysis revealed that 305 (6.0%) subjects had diabetes mellitus (198 on the basis of fasting plasma glucose of > or =7.0 mmol/l (> or =126 mg/dl) and an additional 107 based on a 2-h glucose tolerance test), 381 (7.5%) had IFG and 361 (7.1%) had IGT. Of these 361 subjects with IGT, only 99 (27.4%) had impaired fasting glucose whereas 262 (72.6%) had normal fasting glucose of <6.1 mmol/l (<110 mg/dl). Of 381 subjects with IFG, 99 (26%) had IGT where as 282 (74%) had normal 2-hr glucose. We conclude that there is a poor correlation between IGT and IFG.

Copper, zinc and magnesium levels in fibrocalculous pancreatic diabetes.

Alterations in trace elements and mineral homeostasis have been documented both in insulin-dependent diabetes mellitus and non-insulin dependent diabetes mellitus. No data are available about trace elements in fibrocalculous pancreatic diabetes, a unique form of secondary diabetes mellitus. This study evaluated the plasma concentrations of copper, zinc and magnesium in this form of diabetes. Twenty-five patients (9 men and 16 women) with fibrocalculous pancreatic diabetes and 25 healthy non-diabetic subjects (16 men and 9 women) were studied. Patients with overt nephropathy were excluded. Plasma copper, zinc, and magnesium levels were analyzed using a GBC 902 double beam absorption spectrophotometer. The effect of glycemic control, microalbuminuria, sex and modality of treatment received on the plasma levels of copper, zinc and magnesium was assessed. Results of the study revealed that plasma copper, zinc, and magnesium levels were comparable between patients with fibrocalculous pancreatic diabetes and control subjects. Plasma copper levels were significantly higher in patients with controlled diabetes (16.15 +/- 0.67 micromol L(-1)) as compared to those with uncontrolled diabetes (13.75 +/- 0.61 micromol L(-1)) and healthy controls (13.91 +/- 0.55 micromol L(-1)). This merits further investigation. Microalbuminuria, modality of treatment received and sex did not influence the levels of these elements in fibrocalculous pancreatic diabetes.

Response of regimens of insulin therapy in type 2 diabetes mellitus subjects with secondary failure.

OBJECTIVE: To find the response of various regimen of combination therapy (Insulin and Glibenclamide) in type 2 diabetes mellitus subjects who failed to respond to maximum doses of glibenclamide (GBC) plus phenformin. METHODS: A total of 188 subjects with secondary sulfonylurea failure who failed to respond to maximum doses of GBC and phenformin were randomised to receive one of the four regimens. Group A (50 patients) received two doses of insulin; Group B (49 patients) received two doses of insulin and GBC 20 mg/day; Group C (43 patients) received morning dose of insulin with GBC 20 mg/day; and Group D (46 patients) received evening dose of insulin with GBC 20 mg/day. Insulin dose was adjusted to achieve an acceptable blood glucose control. Control of diabetes was revaluated at three months post-treatment period. RESULTS: Age, duration of diabetes, weight, body mass index (BMI) and biochemical parameters were comparable in all four groups at admission. Dose of insulin was 0.83 +/- 0.07, 0.86 +/- 0.06, 0.46 +/- 0.04 and 0.39 +/- 0.03 units/Kg/day in groups A, B, C and D, respectively. Comparing groups A and B, we found that the dose of insulin (IU/kg/day) required to achieve acceptable fasting blood glucose (FBG) did not differ significantly. Similarly, comparison between Groups C and D did not reveal any significant difference in insulin dose. Mean hospital stay required to achieve an acceptable FBG was 8.42 +/- 0.34, 11.95 +/- 1.11, 8.59 +/- 0.61 and 7.10 +/- 0.48 days in groups A, B, C and D, respectively (p = 0.013). On comparing the four treatment regimens, at three months follow-up, there was a significant increase in bodyweight in Group C; also there was an increase in fasting blood glucose in all the groups except in Group D. CONCLUSIONS: Continuation of GBC in type 2 diabetes mellitus subjects who fail to respond to maximum doses of GBC plus phenformin and who need two doses of insulin for control has no added advantage over giving insulin alone. In subjects controlled on a single dose of insulin with glibenclamide it is preferable to give an evening dose rather than a morning dose.

Regular ovulatory menstrual cycles in a case of Sheehan's syndrome.

In this report we describe an unusual case of postpartum pituitary necrosis who had clinical and biochemical suggestion of decreased thyrotroph, somatotroph, lactotroph, and corticotroph reserve but continued to have regular ovulatory menstrual cycles.

Pregnancy in Sheehan's syndrome: a report of three cases.

Postpartum pituitary necrosis (Sheehan's syndrome) is a relatively common clinical disorder in developing and underdeveloped areas of the world. Sheehan's syndrome has a spectrum of presentations. Spontaneous pregnancy in such patients is a rare occurrence. Three patients with clinical and hormonal evidence of postpartum pituitary necrosis conceived spontaneously during the follow up period. Pregnancy though rare may occur either due to sparing or recovery of gonadotroph function in such patients.

Spontaneous remission in idiopathic hyperprolactinemia.

In this report we describe a 37 year old lady who was demonstrated to have hyperprolactinemia causing amenorrhea-galactorrhea syndrome. Computerized tomography scan done twice did not reveal any sellar or suprasellar abnormality and there was no clinical or biochemical evidence of primary hypothyroidism. She had regression of galactorrhea, resumed regular menstrual cycles, and conceived twice on bromocriptine therapy. Following her second delivery she noticed spontaneous remission of galactorrhea and, prolactin levels estimated multiple times were normal.

Pregnancy in premature ovarian failure: a possible role of estrogen plus progesterone treatment.

Premature ovarian failure (POF) is a common occurrence in women during their reproductive years. There is paucity of data on spontaneous ovulation and subsequent pregnancies in such women. In this report, we describe three women with POF, two of whom had spontaneous conceptions and the third resumed spontaneous regular menstrual cycles. All these women had received oestrogen-progesterone tablets for many cycles (ethyl oestradiol 0.05 mg and levonorgestrel 0.25 mg a day, 21 days a month). We speculate about the possibility of elevated gonadotrophins causing down regulation of gonadotrophin receptors and restoration of the sensitivity of the few remaining ovarian follicles by lowering of serum gonadotrophins with oestrogen therapy.

Prevalence of obesity in adults--an epidemiological study from Kashmir Valley of Indian Subcontinent.

OBJECTIVE: Obesity is a health problem in the majority of the developed countries and is emerging as a serious problem in the developing countries. In this study we examined 5083 Kashmiri adults to determine the prevalence of obesity. METHODS: In this epidemiological study, after multistage sampling procedure from all the six districts of Kashmir Valley, 5083 Kashmiri adults (males and non-pregnant females of > or = 40 years age) were examined for body mass index (BMI) and waist to hip ratio (WHR). RESULTS: Out of 5083 study subjects, 2496 were males and 2587 were females. BMI ranged between 14.6 to 38.5 kg/m2 in males and between 13.6 to 42.6 kg/m2 in females. BMI in females was comparatively more than that in males (23.88 +/- 3.94 Vs 22.30 +/- 3.11, p < 0.001). WHR ranged between 0.68 to 1.16 in males and between 0.65 to 1.16 in females. Again females had comparatively more WHR than their male counterparts (0.935 +/- 0.055 vs 0.926 +/- 0.055, P < 0.001). According to BMI, the overall prevalence of obesity in the study population was 15.01%; the prevalence of obesity in males was 7.01% and in females 23.69%. CONCLUSIONS: We conclude that obesity is a growing problem even in developing regions like ours. It is more common in females and in urban population.

Prevalence and pattern of sick euthyroid syndrome in acute and chronic non-thyroidal illness--its relationship with severity and outcome of the disorder.

BACKGROUND: Non-thyroidal illness is a common cause of alterations in thyroid hormone economy in absence of underlying intrinsic thyroid disorder. OBJECTIVE: To study the prevalence and pattern of alterations in thyroid hormone economy in various non-thyroidal illnesses in our region and also to correlate these alterations with the severity and outcome of the non-thyroidal illness. MATERIAL AND METHODS: We analyzed circulating T3, T4, TSH in 382 patients with non-thyroidal illness (285 acute and 97 acute on chronic) and correlated the alterations with severity and outcome of the non-thyroidal disorder. The patients had one or more organ failure at the time of enrollment to the study. The hormones were estimated at the onset of sickness, and at 3rd and 24th week. T3, T4 and TSH in 75 age and sex matched euthyroid subjects were taken as controls. RESULTS: T3 (mean +/- SEM) was significantly reduced at the onset of illness, in both acute and chronic patient groups (1.61 +/- 0.05 nmol/l) compared to that in the controls (3.17 +/- 0.06 nmol/l). In spite of clinical improvement in most instances, T3 continued to remain low in the 3rd week (1.49 +/- 0.11 nmol/ l) but increased (2.14 +/- 0.09 nmol/l) in 24th week. Low T3 was found in 93 (32.6%) cases with acute illness in 20 (20.6%) cases with chronic illness. A combination of low T3 and T4 was found in 35 (12.3%) of cases with acute and 15 (15.5%) with chronic illness. Although serum TSH showed noticeable fall and rise in some individuals, no significant difference in mean TSH was observed during any period of illness compared to that in the controls. Severity of illness correlated with decrease in T3 (r=0.58) and T4 (r=0.38). A low T3 and T4 with low or undetectable TSH were associated with increased mortality. At the onset of acute illness low T3 was seen in 113 (29.6%, low T3 -low T4 in 50 (13.1%), high T4 in 28 (7.3%) lowT3-lowT4- low TSH in 10 (2.6%) and low T4 alone in 4 (1%) patients. Fifty one 1 (13.4%) of our patients demonstrated alterations in TSH in presence of normal T3 and T4-26 patients had decreased TSH while as 25 had increased TSH. Of 118 patients who followed at 24 weeks, 11 (9.3%) had low T3, 7(5.9%) had low T3- low T4 and 13 (11%) had elevated TSH. CONCLUSION: Pattern and prevalence of sick euthyroid syndrome in this part of the world, a recognized iodine deficient region, appears to be similar to that reported elsewhere. Important finding in our study was higher percentage of TSH elevation, which we believe to reflect the underlying iodine deficiency state of our community. Besides a significant number of subjects persisted with alterations in thyroid functions even after 6 months of therapy. Though the severity of thyroid hormone derangement correlated with severity of sickness, the derangement was similar in acute vs. acute on chronic nonthyroidal illnesses.

A critical evaluation of signs and symptoms in the diagnosis of Addison's diseases.

OBJECTIVES: To determine the usefulness of clinical symptoms and signs in the diagnosis of Addison's disease. METHODOLOGY: A retrospective, hospital based study from analysis of case records of over 12 years period (1988-1999). Individual or groups of signs and symptoms in 66 patients of confirmed Addison's diseases were compared with 76 subjects with normal ACTH stimulation test, when clinical presentations were similar. RESULTS: Age spectrum of the two groups was similar. Signs and symptoms like weakness, weight loss, gastro-intestinal disturbances, skin/mucosal pigmentation and blood pressure were not statistically different between the two groups. Similarly blood glucose, sodium and potassium were not different between the two groups. Combination of three or more symptoms/signs had a high predictive value of diagnosing the disease than any individual or a combination of < 3 signs/symptoms (P=0.033). CONCLUSIONS: Combination of skin and mucosal pigmentation with gut disturbances and weight loss carried high predictive value in diagnosis of Addison's disease, while individual sign and symptom has poor differentiating value.