Case Study. Group 2. Mohsin Dahodwala, Adriana Kraljevic, Alexis Ray, Alyssa Steege

Transcription

1 Case Study Group 2 Mohsin Dahodwala, Adriana Kraljevic, Alexis Ray, Alyssa Steege

2 Initial Presentation of Patient 27 year old female admitted to the hospital with complaints of Nausea Vomiting Confusion Hyponatremia (low blood sodium) Well until 1 week before admission Nausea and nonbloody, nonbilious emesis occurred She did not seek medical care Day before admission Recurrent vomiting associated with eating Still able to drink large amounts of water Became confused and was unable to follow directions or walk

3 Admission of Patient In ER, she was lethargic and did not respond to questions or commands. BP initially 96/64, but dropped to 73/54 upon remeasurement. Body temp was 36.1 C (normal range 36.1 C-37.2 C) Respiratory Rate was 16 breaths per minute 100% O2 saturation on room air Speech incoherent Cried intermittently Moved arms and legs unpurposely IV was obtained and 700ml of saline was administered

4 First Lab Report (at other hospital) Sodium was 104 mmol per liter (reference range, 135 to 145l) Potassium 5.1 mmol per liter (reference range, 3.5 to 5.0) Chloride 74 mmol per liter (reference range, 98 to 107) Carbon dioxide 19 mmol per liter (reference range, 24 to 32) Glucose 114 mg per deciliter (6.3 mmol per liter; reference range, 70 to 110 mg per deciliter The anion gap was 11 mmol per liter (reference range, 3 to 15) Blood level of aspartate aminotransferase was 37 U per liter (reference range, 10 to 32) Alanine aminotransferase 37 U per liter (reference range, 7 to 35) The blood levels of total protein, albumin, total bilirubin, and lipase were normal, as were the results of renal-function tests Human chorionic gonadotropin and a urine drug screen were negative

5 Question #1 Why would the patient s carbon dioxide levels be low? A. Her body is trying to use it to replace oxygen B. She is breathing too slowly C. There is too much oxygen in the air around her D. Her blood ph is low E. She is breathing too deeply

6 Question #1 Why would the patient s carbon dioxide levels be low? A. Her body is trying to use it to replace oxygen B. She is breathing too slowly C. There is too much oxygen in the air around her D. Her blood ph is low E. She is breathing too deeply

7 Question #2 Why would you give a patient Hypertonic saline on transport? A. It helps with the patient transport B. It increases the exchange of Oxygen and Carbon Monoxide C. It has to go along when given Ketamine D. It increases electrolyte imbalance E. It calms the patient

8 Question #2 Why would you give a patient Hypertonic saline on transport? A. It helps with the patient transport B. It increases the exchange of Oxygen and Carbon Monoxide C. It has to go along when given Ketamine D. It increases electrolyte imbalance E. It calms the patient

9 Patient History as told by family Patient was described to Mass. Gen by family members as: Healthy Used an etonogestrel implant (birth control implant) A graduate student, resided in the southern United States She was visiting New England with friends She drank alcohol occasionally and did not smoke tobacco or use over-thecounter medications. Her mother had had breast cancer, but there was no family history of autoimmune disease.

10 Mass. General Examination Temperature was 36.7 C Blood pressure 102/57 mm Hg Pulse 92 beats per minute Respiratory rate 12 breaths per minute Oxygen saturation 100% on room air Somnolent (abnormally drowsy) and did not respond to commands She opened her eyes and withdrew in response to painful stimuli Pupils were round, equal, and reactive to light.

11 Mass. General Examination cont. Mucous membranes were moist. The first and second heart sounds were normal, without murmurs The breath sounds were normal in both lungs, without wheezing or rhonchi. Bowel sounds were present, and the abdomen was soft, nondistended, and nontender on palpation. The edge of the liver was not palpable There was no splenomegaly The arms and legs had no edema

12 Mass. General Lab Reports Variable Patient s Normal Hematocrit % Hemoglobin (g/dl) Sodium (mmol/l) Chloride (mmol/l) CO2 (mmol/l) Sodium 158 None

13 Question #3 What is a hematocrit? A. Amount of plasma in blood B. Amount of leukocytes in blood C. Amount of red blood cells in the blood D. How much oxygen your blood carries E. Amount of platelets in your blood

14 Question #3 What is a hematocrit? A. Amount of plasma in blood B. Amount of leukocytes in blood C. Amount of red blood cells in the blood D. How much oxygen your blood carries E. Amount of platelets in your blood

15 Tests Performed CT scan of head revealed no acute intracranial hemorrhage, infarction, or intracranial mass lesions Chest radiography had low lung volumes, but no focal consolidation (region of lung filled with liquid) or pulmonary edema Normal cardiac silhouette and no pleural effusions

16 Making a Diagnosis Salient features of patient presentation: Intermittent vomiting Confusion and agitation Hyponatremia with high urine osmolality and high urine sodium levels Hypotension Mild, isolated hyperkalemia Normal anion-gap metabolic acidosis Still had hyponatremia and high blood levels of antidiuretic hormone, even after normal blood volume and fluids were restored intravenously Narrows diagnosis to salt-wasting syndromes, drug or toxin exposure, or hormonal alterations

17 Quick Rule Outs Cerebral salt-wasting syndrome low blood sodium levels and dehydration caused by a brain tumor. Pregnancy No evidence in CT scan Hyponatremia is typically only mild in pregnant women Pregnancy test was negative Hypothyroidism Can cause hyponatremia with excess ADH disrupting sodium handling in renal tubes Thyrotropin level was normal Syndrome of inappropriate ADH secretion Will be considered more if no alternatives are found

18 Question #4 Why would antidiuretic hormone (ADH) levels be high if she has hyponatremia? A. ADH promotes sodium and water excretion B. The low blood sodium triggered the release of more ADH C. ADH throws off the Na/K pump D. ADH is made out of sodium E. Excess ADH overwhelms the pituitary

19 Question #4 Why would antidiuretic hormone (ADH) levels be high if she has hyponatremia? A. ADH promotes sodium and water excretion B. The low blood sodium triggered the release of more ADH C. ADH throws off the Na/K pump D. ADH is made out of sodium E. Excess ADH overwhelms the pituitary

20 Diuretic Misuse Diuretic: a substance that increases production of urine Increases urine production by inhibiting the sodium-chloride transporter in distal tubule of kidney nephron. Misuse is often associated with eating disorders (high prevalence in women) Hyponatremia caused more commonly by thiazide than loop diuretics Thiazide induced hyponatremia develops within 1 or 2 weeks after initiation of the diuretic Patients who develop hyponatremia due to diuretic misuse also have euvolemia, but this is more common in lean elderly women

21 Question #5 Why is a diagnosis of the misuse of thiazide diuretics a greater possibility than the misuse of loop diuretics? A. Thiazide diuretics are more addicting B. Potassium levels in the patient are high C. Sodium levels in the patient are low D. Loop diuretics were used to treat this patient s edema E. None of the above

22 Question #5 Why is a diagnosis of the misuse of thiazide diuretics a greater possibility than the misuse of loop diuretics? A. Thiazide diuretics are more addicting B. Potassium levels in the patient are high C. Sodium levels in the patient are low D. Loop diuretics were used to treat this patient s edema E. None of the above

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24 MDMA Also known as molly or ecstacy Complications of using this drug: Hypertension: high blood pressure Tachycardia: rapid heart rate Rhabdomyolysis: breakdown of muscle tissue Serotonin syndrome: high levels of serotonin in the body Severe hyponatremia (low blood sodium) which can result in death or a coma Hyponatremia can be caused through misuse of MDMA because of induced antidiuretic hormone release and excessive consumption of water Patients typically have hypovolemia, although some can have euvolemia

25 Question #6 Which of the following is the carbon structure of 3,4- Methylenedioxymethamphetamine (MDMA)? A. B. C. D. E.

26 Question #6 Which of the following is the carbon structure of 3,4- Methylenedioxymethamphetamine (MDMA)? A. B. C. D. E.

27 Adrenal Insufficiency Primary Adrenal Insufficiency: Damage to adrenal glands Secondary Adrenal Insufficiency: Lack of corticotropin caused by pituitary or hypothalamic disease Primary adrenal insufficiency hyponatremia caused by: Cortisol deficiency Aldosterone deficiency Patients can have either hypovolemia (decreased blood volume) or euvolemia (normal blood volume)

28 Question #7 If the patient is suffering from primary adrenal insufficiency... A. Cortisol levels are increased B. The adrenal gland is fully functioning C. Corticotropin releasing hormone is not being inhibited D. Corticotropin levels are decreased E. The patient will have hypertension

29 Question #7 If the patient is suffering from primary adrenal insufficiency... A. Cortisol levels are increased B. The adrenal gland is fully functioning C. Corticotropin releasing hormone is not being inhibited D. Corticotropin levels are decreased E. The patient will have hypertension

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31 Question #8 Which of the diagnoses do you think best fits the patient s symptoms? A. Diuretic misuse B. MDMA use C. Primary Adrenal Insufficiency D. Secondary Adrenal Insufficiency E. None of the above

32 Question #8 Which of the diagnoses do you think best fits the patient s symptoms? A. Diuretic misuse B. MDMA use C. Primary Adrenal Insufficiency D. Secondary Adrenal Insufficiency E. None of the above

33 Why We Can Rule Out Other Diagnoses Diuretic Misuse MDMA Use A diuretic would lead to loss of potassium and hydrogen, leading to hypokalemia and alkalosis in patient, mild hyperkalemia and acidosis are observed No hypertension Drug screen was negative; patient denied using recreational drugs Secondary Adrenal Insufficiency Corticotropin releasing hormone and adrenocorticotropin levels were high Tests were done that showed that hypothalamus and pituitary were responding normally

34 Primary Adrenal Insufficiency (Addison s Disease) Rare disorder Most common cause in high-income countries: autoimmune adrenalitis Symptoms: Fatigue Dizziness Gastrointestinal illness Salt craving Hyperpigmentation (almost always present on patients with primary adrenal insufficiency) Eosinophilia

35 Patient was Missing Typical Symptoms Hyperpigmentation dark spots of excess pigment on skin Cortisol deficiency leads to loss of negative feedback; thus, corticotropin levels are elevated, leading to high levels of melanin and pigmentation. Eosinophilia High eosinophil levels αmsh Melanogenesis

36 Hyperpigmentation

37 Tests for Addison s Disease Despite lack of hyperpigmentation, physicians decided to test for Addison s Disease. Measured cortisol levels Measured corticotropin baseline Cosyntropin stimulation assay

38 Cortisol Baseline Cortisol levels found to be 7.2 ug/dl this is a normal result; for Addison s Disease, low cortisol expected. In presence of critical illness (such as patient) cortisol levels expected to be high. So considering context, cortisol lower than expected.

39 Corticotropin Baseline Found to be very high (896 pg/ml; baseline 6-76) Suggests Addison s Disease

40 Question #9 How could you directly measure adrenal gland function? A. Measure estrogen hormone levels B. Check salt concentration in urine C. Inject corticotropin and measure response D. Run an oxytocin activity assay E. A and D

41 Question #9 How could you directly measure adrenal gland function? A. Measure estrogen hormone levels B. Check salt concentration in urine C. Inject corticotropin and measure response D. Run an oxytocin activity assay E. A and D

42 Cosyntropin Stimulation Assay Cosyntropin is an active fragment of corticotropin The idea is to inject cosyntropin intravenously and measure adrenal response Cosyntropin

43 Question #10 After injection of cosyntropin, cortisol levels are measured after 30 minutes and 60 minutes. If a patient s adrenal glands are functioning normally, which of these test results are possible? (assume baseline cortisol level of 4.5 ug/dl) A. 30 minutes: 6.7 ug/dl, 60 minutes: 8.9 ug/dl B. 30 minutes: 2.5 ug/dl, 60 minutes: 1.3 ug/dl C. 30 minutes: 10.7 ug/dl, 60 minutes: 10.8 ug/dl D. 30 minutes: 4.6 ug/dl, 60 minutes: 4.5 ug/dl E. A or C both indicate appropriate adrenal function

44 Question #10 After injection of cosyntropin, cortisol levels are measured after 30 minutes and 60 minutes. If a patient s adrenal glands are functioning normally, which of these test results are possible? (assume baseline cortisol level of 4.5 ug/dl) A. 30 minutes: 6.7 ug/dl, 60 minutes: 8.9 ug/dl B. 30 minutes: 2.5 ug/dl, 60 minutes: 1.3 ug/dl C. 30 minutes: 10.7 ug/dl, 60 minutes: 10.8 ug/dl D. 30 minutes: 4.6 ug/dl, 60 minutes: 4.5 ug/dl E. A or C both indicate appropriate adrenal function

45 Results of Patient s Cosyntropin Assay? Her cortisol was 4.5 ug/dl before administration of test After 30 minutes, her cortisol level was 4.6 ug/dl; after 60 minutes, it was 4.5 ug/dl. With a functioning adrenal gland, cosyntropin injection should cause an increase in cortisol The increased cortisol will later negatively feedback to inhibit corticotropin Patient showed no increase in cortisol levels in response to cosyntropin injection. This indicates Primary Adrenal Insufficiency (Addison s disease)

46 Treatment Treated by giving glucocorticoids (hydrocortisone) to replace adrenal gland cortisol output Treated by giving mineralocorticoids (fludrocortisone) to replace adrenal gland aldosterone output But there are still many problems with glucocorticoid and mineralocorticoid treatment due to: Varying glucocorticoid sensitivity from patient to patient It does not simulate normal pulsatile secretion of corticotropin and cortisol Exact amounts needed cannot be measured precisely

47 Management Dietary treatment; increase salt intake This can cause other problems like hypertension and edema Avoid too much sun exposure This can cause excess sodium and water loss Condition is chronic, not acute After more probing history questions, it was discovered that she had been feeling fatigued for months. Hyperpigmentation was missed in initial assessment.

48 Autoimmune or another cause? Tested for 21-hydroxylase antibody, commonly seen in autoimmune primary adrenal insufficiency Her results were negative, but that does not definitively rule out autoimmune possibility other antibodies may be involved for which tests are not available Could do an abdominal CT to check for cancer, tuberculosis, granulomatous diseases, or other non-autoimmune causes Her physicians elected not to do that because there was not evidence to suggest these diagnoses

49 Follow Up After discharge, patient was receiving 10 mg hydrocortisone at 8am and 5 mg at 3pm daily, along with 0.1 mg fludrocortisone. Fatigue in the morning attributed to taking the hydrocortisone too late in the morning Hands were puffy attributed to excessive fludrocortisone administration Bruising, muscle loss, 14 lb weight gain attributed to too large of a hydrocortisone dose Medication was modified: 10 mg hydrocortisone at 7 am, followed by 2.5 mg in the afternoon. Fludrocortisone was skipped twice a week. After another follow up three months later, symptoms had resolved and patient was doing remarkably well.

50 Bonus Question Which famous person was also diagnosed with Addison s disease? A. Selena Gomez B. Meryl Streep C. David Bowie D. Martin Luther King Jr. E. John F. Kennedy

51 Bonus Question Which famous person was also diagnosed with Addison s disease? A. Selena Gomez B. Meryl Streep C. David Bowie D. Martin Luther King Jr. E. John F. Kennedy