Ossification of the auricular cartilages is a rare complication of Addison’s disease(1,2), having been reported in 30 previous case reports (3).
We present the case of a 55 year old man with longstanding Addison’s disease who developed bilateral, spontaneous hardening of the auricular cartilages in the 12 months following an episode of acute gallstone pancreatitis. He denied any history of trauma or cold injury to his ears, nor any history of hypercalcaemia or malignancy. Imaging is consistent with ossification rather than ectopic calcification.
His past medical history includes Addison’s disease (15 years), autoimmune hypothyroidism and pernicious anaemia. Medications included Cortisone acetate, Fludrocortisone, Thyroxine, B12 injections. Of significance his cortisone dose was daily only (50mg mane), leading to persistent elevation of ACTH and pigmentation, but no history of Addisonian crisis.
The episode of gallstone pancreatitis (lipase 2880 Units/L (NR <60)), was complicated by an Addisonian crisis, requiring intensive care treatment with intravenous hydrocortisone and fluid resuscitation. During his admission, he suffered a 24 hour period of hypocalcaemia (ionized calcium 1.05mmol/L (NR 1.15-1.30) without acidosis or renal impairment. His recovery was uneventful, but he noticed that his ears became progressively hardened.
Ossification of the ear cartilages is a rare entity that occurs mostly in males (2), and has been described as a complication of mechanical or cold injury (frostbite) to the ears, but also systemic disorders including diabetes, primary hyperparathyroidism, panhypopituitarism, hypothyroidism and scleroderma (1,2,3). The commonest endocrine association is with Addison’s disease but the mechanism has been unclear (2). Recently, POMC and ACTH have been identified as key players in endochondral ossification, through interactions with Melanocortin receptors found on mesenchymal stem cells and chondrocytes (3).
We propose that this case demonstrates a temporal linkage between raised ACTH, acute inflammation and the onset of auricular ossification in Addison’s disease.