Madam, I read with interest the case reported by Dr. A. Jabbar in April, 1994 issue of JPMA. The first case of a 72 years old lady might have been Addison’s Disease, the cause being tubereulosis of adrenal glands along with liver and possible lung lesion. There is no mention of pigmentation though in dark skinned races it is difficult to detect. It may not be present depending on the level of aldosterone. It is not clear why in another hospital a diabetic was given dexamethasone. However, on her second admission to the Aga Khan Univer­sity she had enlarged liver and as she was a very sick woman perhaps a liver biopsy was not attempted. This is Pakistan where tuberculosis is still a major problem and in any unexplained fever one has to think of tuberculosis. CT scan of chest showed a lung lesion. If any empirical treatment was to be given the justification was for anti-tubercular drugs. Looking at the number, the total cost of investigations would be no less than Rs. 1,50,000. In the second case of a 41 years old man the initial investigation did not give a clue to diagnosis but portal hypertension was there presumably due to liver disease. The hematological picture was that seen often in sub-acute infections. Hypersplenism is a vague phenomenon and not a fmal diagnosis. Since he was severely anemic, I feel he should have had a blood transfusion and a needle liver biopsy which would have given the diagnosis straight away and save him from splenectomy and other investigation at a considerable cost.

A.H. Haquani
20, Ghafur Chambers, Haroon Road, Karachi.