Hiya! I’m back with another case presentation. Just like case 2, I presented this during my didactics. This format is a bit different than the last one as this case I followed for awhile. Again, at each stop sign, stop and answer the questions. Work on practicing putting your skills to use!
HPI:
61 y/o F presenting with persistent hypoglycemia. EMS initially called to scene for AMS. BS found to be in the 30’s. D50 given en route with improvement of mental status to A&Ox2. Paperwork from her SNF facility had shown recent metabolic encephalopathy secondary to UTI and persistent hypoglycemia. Patient complains of overall body pain. No other history could be provided in the ED.
Make a list of possible differentials for these symptoms. It is okay to have a broad list to start off with!
HISTORY:
PMHx: Breast CA, HLD, TIA
PSHx: tubal ligation, tracheostomy (now removed), PEG tube (now removed)
Meds from SNF: midodrine, mirtazapine, apixaban, atorvastatin, bethanechol, alprazolam, ferrous sulfate, mag oxide, folic acid
No other history could be obtained.
Initial VS: 36.7’F, 88 BPM, 15 RR, 128/78 mmHg, 98% on RA
Physical Exam:
General: AOx2 NAD
Head: nontraumatic, normocephalic.
Neck: supple, nontender, FROM.
ENT: PERRL, EOMI, normal conjunctiva/sclera, no nystagmus. Dry oral mucosa
Cardiac: RRR, no murmurs, rubs, gallops.
Lungs: CTAB, no rales, rhonchi, wheezing.
Abdomen: nontender, soft, nondistended, no guarding, normal bowel sounds.
Extremities: BLE decreased ROM due to pain, no deformities, 2+DP/Rad, no cyanosis or edema.
MSK: no midline spine tenderness. no joint tenderness.
Skin: Pale. No rashes.
Neuro: CN 2-12 grossly intact, no obvious motor or sensory deficits.
What are your differentials based off of this information? What is moved up on your list? What is moved down? What is crossed off?
What would you like to order to evaluate this patient?
Initial labs:
POC: 58 > 122 > 61 (given 2 amps of D50)
CBC: WBC 3.3, Hgb 11.3, plt 106
BMP: Na 135, K 3.7, Cl 103, CO2 23, BUN 11, Cr 0.8, Ca 8.9
UA: + ketones, 6-10 WBC’s, bacteria rare
COVID: +
CXR: mild pulmonary vascular congestion. R basilar opacities and effusions.
Review your differential diagnosis list. What do you want to order to further evaluate this patient? What do you want to do to treat this patient?
Initial Plan: continuous D10 infusion, accuchecks q4, monitoring.
Day 2: Mental status continued to deteriorate. Became more confused, would wax and wane between A&Ox1 and x2. BP started to slowly drop. lowest BP 93/57mmHg. Endocrine consulted. Cortisol levels, sulfonylurea levels, proinsulin, c-peptide, and insulin levels pending.
Review of records: Patient was recently seen in hospital in June and August with full acute encephalopathy workup including EEG, MRI, CT, LP. All returned normal.
Day 3: BP ranged from 93/50-108/57. Stopped eating much. Nauseated and vomiting. Became more confused, very drowsy. BG ranged from 90-110’s with D10 infusion. CT abd/pelvis obtained: No adrenal abnormality seen. Small hiatal hernia. Atherosclerotic disease throughout abdominal vasculature. Infrarenal aortic aneurysm: 2.2×2.6cm superiorly and 3.1×3.0 cm inferiorly. Chronic scarring at lung bases.
Dietician and palliative consulted. Persistent hypokalemia at 3.2. Persistent hypomagnesemia at 1.6
Day 4: BG no higher than 130 overnight. BG during the day continued to drop. 2 episodes of BP improving in 140’s systolic, remainder in low 100’s systolic. Eating very little. Nausea and vomiting. Persistent hypokalemia and hypomagnesemia. Poor PO intake.
cortisol level- 0.20 low (baseline)
Insulin level- normal at 4.7
C-peptide- normal at 0.73.
Pro-insulin and toxicology pending. Awaiting stim test.
Day 5: BG dropped to 60’s with D10 infusion. Additional 250mL bolus given with improvement to 94. Poor oral intake. Nausea and vomiting improved with continued scheduled Zofran. Increased bilateral knee and back pain. BP dropping into the 80’s systolic. Potassium now 3.0 and Mg 1.6 despite repletion earlier. Throughout the day, BG slowly dropping into the 80’s.
Endocrine recommends consider dose of hydrocortisone. Late in the afternoon given dose of Decadron, 4mg IV q8 hours.
Day 6: BG post Decadron jumped to 200’s. D10 infusion stopped. Confused, but more awake now. Poor PO intake. BP 100-137 systolic. Decadron changed to qd. Hypokalemia 3.2 and hypomagnesemia 1.8.
Day 7: BG normalizing with less frequent Decadron doses. Stopped eating completely. Re-started on a small amount of IVF. BP stabilizing.
Stim test post ACTH administration: 1.17 –> 5.28–> 7.90
PO fludrocortisone 0.1 mg qd and PO hydrocortisone 15 mg total, 5 mg TID started
Day 8: Continues to have diffuse myalgias and bone pain. Started eating a bit again. No more nausea/vomiting. Confused, but alert. Blood sugar stabilized in the 110’s. Per endocrine, decreased hydrocortisone to 10 mg total, 5 mg BID. Potassium 3.9. Magnesium 2.0. Was discharged back to SNF to continue outpatient endocrine follow up.
After looking through this patient’s chart, what is the diagnosis? Or what are your top diagnoses?
FINAL DIAGNOSIS: Primary adrenal insufficiency
Below are some pictures to help remind you of what the HPA axis is and important information on adrenal glands. I had to completely look this up while taking care of this patient because I hadn’t seen a case like this yet!
Treatment:
We suggest replacement with a short-acting glucocorticoid, hydrocortisone, in two or three divided doses as the glucocorticoid of choice for the management of chronic primary adrenal insufficiency [2]. We suggest using the lowest glucocorticoid dose that relieves symptoms of glucocorticoid deficiency.
Short-acting regimens roughly mimic the normal diurnal rhythm.
Most patients with primary adrenal insufficiency eventually require mineralocorticoid replacement to prevent sodium loss, intravascular volume depletion, and hyperkalemia. Fludrocortisone (9-alpha-fluorohydrocortisone), a potent synthetic mineralocorticoid, is given orally in a usual dose of 0.1 mg/day. A lower dose (such as 0.05 mg/day) may be sufficient in patients receiving hydrocortisone, which has some mineralocorticoid activity. Rare patients are sufficiently replaced with hydrocortisone alone and become hypertensive, hypokalemic with even 0.05 mg Florinef twice a week.
Below is the flowchart for how to interpret/do the cosytropin stimulation test.
And congrats on going through another case! Until next time, Cheers.
