Blue Tongue as a Presenting Sign of Primary Adrenal Insufficiency

Primary adrenal insufficiency, also known as Addison's disease, is a rare endocrine disorder characterized by inadequate production of the adrenal hormones cortisol and aldosterone. The presentation of this clinical disorder is often insidious, and thus difficult to recognize, leading to potentially fatal outcomes. Patients often present with lethargy, shock, and hyperkaliemia with hyponatremia. We describe herein the first reported case, to our knowledge, of a patient with blue tongue as an early presenting sign of adrenal insufficiency. A 49 yo woman was referred to the Department of Otolaryngology at the University of Kansas Medical Center for evaluation of bluish discoloration in her tongue. She first noticed this bluish discoloration on her tongue 6 months earlier. There was slow progression of discoloration onto her buccal mucosa. She was completely asymptomatic, denying any pain, dysphagia, bleeding, or fatigue. A previous workup had revealed mild anemia, mildly elevated LFT's, and some intermittent hyponatremia. Colonoscopy, which was performed to rule out Peutz-Jaghers syndrome, was negative. Her medical history was notable for depression and a distant seizure episode for which she was no longer on antiepileptic medication. Physical examination revealed patches of bluish-brown discoloration throughout the dorsal tongue and bilateral buccal mucosa (Figure 1). She was also noted to have a slightly tanned appearance to her skin, which she attributed to a recent trip to Hawaii. Some small dark spots were noted in the iris. The remainder of her head and neck examination was within normal limits.