step2CK Addison's crisis and disease 진단 및 치료
운영자 / 2005-09-16 11:30:19
A 30-year-old woman was admitted to hospital because of dizziness, nausea, vomiting, anorexia and weight loss. Nine months before, she was sent to a state tuberculosis clinic with fever, night sweats, cough and weight loss. In that clinic, active pulmonary tuberculosis was diagnosed by X-ray, ARB in sputum and sputum culture. She was treated with a 4 drug combination therapy. After she was discharged from hospital, her
symptoms, especially nausea, vomiting and loss of appetite, persisted. She was examined in many clinics and these complaints were attributed to pulmonary tuberculosis and the side-effects of the anti-tuberculosis drugs. She was given saline infusions many times to
correct her hyponatremia but her problems were not resolved. During her physical examination her blood pressure was 90/50 mmHg. Because of severe orthostatic hypotension, she could not stand up. She weighed 42 kg. She had generalized hyperpigmentation and darkening with prominent gingival and buccal mucosa. The thyroid gland was diffusely enlarged. The results of the laboratory examination were as follows:
WBC, 6700/mm3 (neutrophil 61%, lymphocyte 23%, monocyte 11%); hemoglobin, 11.4 g/dl; hematocrit,33.5%; platelets, 276,000/mm3; ESR, 110 mm/h;fasting blood glucose, 79 mg/dl; BUN, 14 mg/dl; uric acid, 9.6 mg/dl; albumin, 3.7 mg/dl; sodium, 129 mmol/l;
potassium, 4.7 mmol/l; chloride, 98 mmol/l; TSH, 0.0514 mIU/ml; free triiodothyronine (FT3), 3.83 pg/ml;free thyroxine (FT4), 1.4 ng/dl; ACTH, 50 pg/ml; cortisol,1.7 µg/dl; antithyroglobulin Ab, (-); antimicrosomal Ab, (-); tuberculin skin test, 22 mm; and sodium in 24 h urine,7.95 g. Which is the most likely diagnosis?
Addion's disease and tuberculosis
Tuberculosis (TB), an infection which can destroy the adrenal glands, accounts for about 20 percent of cases of primary adrenal insufficiency in developed countries. When adrenal insufficiency was first identified by Dr. Thomas Addison in 1849, TB was found at autopsy in 70 to 90 percent of cases. As the treatment for TB improved, however, the incidence of adrenal insufficiency due to TB of the adrenal glands has greatly decreased.
Symptom
chronic, worsening fatigue ,muscle weakness ,loss of appetite ,weight loss
Lab
Hyponatremia ,Hypochloremia ,Hyperkalemia ,Hypoglycemia
Diagnosis
Corticotropin Stimulation Test
Management
Acute IV Cortisol
Chronic Replacement Hydrocortisone AND Mineralocorticoid
