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Discussion Though the clinical scenario of both AML and adrenal insufficiency may be individually familiar, the coexistence of both disease processes in the same patient is relatively rare. Some obscure clinical presentations in this patient introduced more difficulties to the diagnoses. For example, while GI symptoms such as nausea, vomiting, diarrhoea and constipation are relatively common in patients with adrenal insufficiency; SBO is an uncommon presentation. So far, there are only few cases of acute mesenteric ischaemia8 and acute abdomen9 10 reported in adrenal insufficiency patients. GI endoscopic and radiographic studies are usually [http://www.selleckchem.com/products/INCB18424.html JAK inhibitor] normal  in patients with adrenal insufficiency presenting with GI symptoms,11 and this was observed in our patient who also had both negative esophagogastroduodenoscopy and colonoscopy studies. The exploratory laparotomy did not identify any ischaemic or mechanic abnormalities of the bowel. Interestingly, an SBO with intussusceptions in an AML patient has been previously reported.12 The initial presentation of neutropenia, macrocytic anaemia with low reticulocytes, normal B12 and folic acid and unintentional weight loss in this patient caused a high suspicion for myeloid dysplasia. On review of labs from his first admission, a mild transient hyponatramia with serum sodium of 131?mEq, came to our attention. Now, we are wondering if this hyponatraemia could be an early hint to  his adrenal insufficiency since hyponatraemia and hyperkalaemia are the two major electrolyte abnormalities of primary adrenal insufficiency. Interestingly, a study in 1997 by Demiro?lu et al7 showed that hyperkalaemia in acute leukaemia was a sign of adrenocortical insufficiency. They compared the adrenal function of 13 acute leukaemia patients with hyperkalaemia (>4.5?mEq) to 20 acute leukaemia patients with normal potassium level. Forty six percent of patients with hyperkalaemia had abnormal ACTH test while  only five percent of acute leukaemia patients were with normal potassium levels. They recommended evaluating adrenal function in all acute leukaemia patients to avoid adrenal insufficiency crisis. If a thought of the adrenal insufficiency in this patient came earlier, could we have avoided his adrenal crisis by early steroid treatment? While the complexity in this patient made the early diagnosis quite difficult. First of all, the imbalance of electrolyte is also quite common in acute leukaemia patient,13 14 and secondly his history of chronic alcohol abuse may also have contributed to his hyponatremia. According to the WHO classification, a myeloid neoplasm with 20% or more blasts in the peripheral blood or bone marrow is the standard to diagnose AML. However, the 20% blast threshold is not a mandate, especially in cases associated with specific genetic abnormalities.