1/11
A 44 y/o man presents with acute abdominal pain, vomiting, and diarrhea. HR 130, BP 90/52. We walk into the room to meet the patient. What do you notice? This should generate at least one hypothesis.
A 44 y/o man presents with acute abdominal pain, vomiting, and diarrhea. HR 130, BP 90/52. We walk into the room to meet the patient. What do you notice? This should generate at least one hypothesis.
2/11
We ask the patient for an old photograph for comparison. His wife pulls out her phone and produces this picture (B) taken about 10 years prior. Pt reports darkening of skin over an 8 year period. What conditions should we consider?
We ask the patient for an old photograph for comparison. His wife pulls out her phone and produces this picture (B) taken about 10 years prior. Pt reports darkening of skin over an 8 year period. What conditions should we consider?
3/11
Let’s consider the hypotension. Physical examination is key in determining which “category” of hypotension we are dealing with. How can physical exam help?
Let’s consider the hypotension. Physical examination is key in determining which “category” of hypotension we are dealing with. How can physical exam help?
4/11
In this case, JVP is low and extremities are warm.
This pattern is characteristic of distributive hypotension. Do any of the conditions listed there match our initial hypothesis?
In this case, JVP is low and extremities are warm.
This pattern is characteristic of distributive hypotension. Do any of the conditions listed there match our initial hypothesis?
5/11
A confirmatory test is our next step.
Serum cortisol is 4.4 ug/dL 60 minutes after a 250 ug injection of ACTH. (Normal adrenal function is established when serum cortisol level is >18 ug/dL after ACTH stimulation.)
A confirmatory test is our next step.
Serum cortisol is 4.4 ug/dL 60 minutes after a 250 ug injection of ACTH. (Normal adrenal function is established when serum cortisol level is >18 ug/dL after ACTH stimulation.)
6/11
We have now confirmed the diagnosis of adrenal insufficiency. The next question is, is it ACTH-dependent or ACTH-independent? A plasma ACTH level is necessary to make this determination. But based on our physical exam, we already know the answer.
We have now confirmed the diagnosis of adrenal insufficiency. The next question is, is it ACTH-dependent or ACTH-independent? A plasma ACTH level is necessary to make this determination. But based on our physical exam, we already know the answer.
7/11
Plasma ACTH level (drawn prior to the stim test) is 872 pg/mL (reference range 10-60 pg/mL).
Plasma ACTH level (drawn prior to the stim test) is 872 pg/mL (reference range 10-60 pg/mL).
8/11
ACTH stimulates melanocortin-1 receptor in the skin –> hyperpigmentation. It usually occurs first in areas of skin under pressure, such as the knuckles or elbows, as in this case below. How long has she been feeling ill? The fingernails provide a clue (thanks @AdamRodmanMD)
ACTH stimulates melanocortin-1 receptor in the skin –> hyperpigmentation. It usually occurs first in areas of skin under pressure, such as the knuckles or elbows, as in this case below. How long has she been feeling ill? The fingernails provide a clue (thanks @AdamRodmanMD)
9/11
Back to our patient. He has primary adrenal insufficiency, most likely isolated autoimmune adrenalitis.
Back to our patient. He has primary adrenal insufficiency, most likely isolated autoimmune adrenalitis.
10/11
Adrenal crisis is usually triggered by acute illness (in this case bacterial colitis). Many of the symptoms/signs can be mistakenly attributed to the acute illness that triggers the adrenal crisis, causing the diagnosis to be missed.
Adrenal crisis is usually triggered by acute illness (in this case bacterial colitis). Many of the symptoms/signs can be mistakenly attributed to the acute illness that triggers the adrenal crisis, causing the diagnosis to be missed.
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