Soo Jin Jung, et al: Malakoplakia of the Kidney in a Patient with Secondary Adrenal Insufficiency had been taking dexamethasone (5 mg, once a day) for the degenerative arthritis for approximately five years up to the time of admission. Three weeks before the admission, she had been hospitalized at NPH due to drowsy mentality for 3 or 4 hours. On the day of admission at NPH, she presented with a fever (38.8oC) and dyspnea. The patient was given antibiotics (ceftriaxone and azithromycin) for 14 days, on suspicion of community-acquired pneumonia. Thereafter, her presenting symptoms were improved, but she complained of consistent pain in the left lower quadrant of the abdomen. Abdomen-pelvis computed tomography (CT) scan was performed, which showed the mass-like lesion in the left renal area suspecting abscess. While being treated with ciprofloxacin, she developed a decreased level of consciousness. Upon physical examination on the day of the admission to our hospital, her initial vital signs were as follows: blood pressure 134/71 mm Hg, pulse rate 95 bits per minute, body temperature 36.4oC, and respiration rate 18 breaths per minute. Her level of consciousness was drowsy. Her breathing sound was clear, and her heart sound was normal without any murmurs. There was no specific finding upon abdominal examination without peripheral edema. Laboratory studies had the following results (reference values): low sodium (Na) levels of 112 mmol/ L (135.0-145.0), potassium (K) 3.4 mmol/L (3.5-5.5), chloride (Cl) 77.0 mmol/L (98-110), total CO2 21.0 mmol/ L (24-30), low serum osmolality 240.0 mOsm (289.0- 308.0), and normal urine osmolality 315.0 (50.0-1200). The thyroid function test was normal. Morning serum cortisol levels decreased to 7.1 (Table 1). Initial urinalysis results showed 3-5 white blood cells/high-power field and yeast-like organisms. In the radiological examination, there was no acute ischemic lesion in the brain magnetic resonance imaging and angiography with neck angiography (3D), and no specific finding on the chest X-ray. Sodium replacement therapy for hypotonic euvolemic hyponatremia had been started from the day of admission. At that stage, secondary adrenal insufficiency due to exogenous steroid was suspected. A low dose adrenocorticotropic hormone (1 μg cosynthropin) stimulation test was conducted to diagnose the secondary adrenal insufficiency. The stimulation test showed that there was adrenal insufficiency; basal level of cortisol 8.56 μg/ dL, peak level during the hour-long test 13.94 μg/dL (Table 2). Steroid hormone (hydrocortisone sodium succinate; solucortef) was replaced. 368 | Vol. 32, No. 6 Sep 2011 Table 1. Results of laboratory analysis performed on the day of hospitalization. White blood cell (no./µL) Neutrophil (%) Lymphocyte (%) Monocyte (%) Eosinophil (%) Hemoglobin (g/dL) Hematocrit (%) Erythrocyte sedimentation rate (mm/h) C-reactive protein (mg/L) D-dimer quantity (ng/mL) Prothrombin time (s) Prothrombin time (INR ) aPTT (s) Glucose (mg/dL) Hemoglobin A1c* (%) Blood urea nitrogen (mg/dL) Creatinine (mg/dL) Sodium (mmol/L) Potassium (mmol/L) Chloride (mmol/L) Total CO2 (mmol/L) Osmolality (mOsm) Thyoid stimulating hormone (µIU /mL) Free T4 (ng/dL) T3 (ng/mL) Cortisol* (µg/dL) Adrenocorticotropic hormone* (pg/mL) Urine osmolality (mOsm) Urine sodium (mmol/L) Urine microalbumin (mg/dL) Result Rerfaenregnece 7,160.0 4,000-10,800 57.5 40-74 25.3 19-48 13.1 3.3-9 1.5 0-7 9.8 12.0-16.0 29.2 37.0-47.0 60.0 0.0-20.0 48.90 0-8 503.0 0-243 15.3 9.8-13.4 1.29 0.91-1.16 24.7 27.9-41.6 117.0 70-110 6.5 4.0-6.0 2.1 5.0-25.0 0.89 0.50-1.40 112.0 135.0-145.0 3.4 3.5-5.5 77.0 98-110 21.0 24-30 240.0 289.0-308.0 1.73 0.35-5.50 1.22 0.89-1.76 1.49 0.6-1.8 7.1 16.79 315.0 50.0-1,200 84.0 1.95 0-3.0 *Test performed on the day after hospitalization. On the third day after admission, her general condition including clear consciousness was improved, with a normal level of serum sodium (136 mmol/L), and her steroid hormone dosage had been gradually tapered down and was maintained at 7.5 mg Korean J Fam Med