His pituitary profile was consistent with secondary adrenal insufficiency: ACTH <1.1 pmol/l (RR <10 pmol/l), with a repeated morning serum cortisol 159 nmol/l (RR 200–600 nmol/l). The pituitary–gonadal axis was preserved: LH 5.9 IU/l (RR 1.7–8.6 IU/l), FSH 4.4 IU/l (RR 1.0–9.0 IU/l), morning testosterone 27.9 nmol/l (RR 6.0–29.0 nmol/l). Prolactin was mildly elevated at 33 ng/ml (RR 2.0–16.0 ng/ml), which was thought to be likely due to the duloxetine. IGF1 was mildly elevated in this rehabilitation phase at 48.5 nmol/l (RR 11.6–37.1 nmol/l), with normal GH 1.1 ng/ml (RR <6.0 ng/ml). Thyroid function profile revealed TSH 0.83 mIU/l (RR 0.27–4.20 mIU/l) and a mildly low free thyroxine (T4) 10.7 pmol/l (RR 12.0–25.0 pmol/l), likely representing a sick euthyroid syndrome in the setting of nonthyroidal illness.The cause of his secondary adrenal insufficiency was considered to be the methadone opioid analgesia commenced in the 6th week of his hospital admission, then maintained owing to neuropathic pain. He had not exhibited clinical signs of adrenal insufficiency during the course of his preceding ICU admission, and he had not received any previous glucocorticoid. The subsequent development of hypercalcaemia in the 6th week of his hospital admission was the presenting feature of his adrenal insufficiency.
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