Case 30: Weak & Nausea

A 33-year-old G1P1 Caucasian female presents with intermittent episodes of weakness, abdominal discomfort and nausea lasting days at a time over the past 3 months. Except for treated hypothyroidism she has no other medical problems.

On exam she is alert, thin, well-tanned, in no acute distress and non-toxic. Vitals are normal except for a BP of 84/56. Her exam is otherwise unremarkable. She looks well hydrated. Her abdomen is benign.  Pelvic exam is refused because “the pain isn’t down there.”

Look at the picture below and use the few clues from the case narrative. What does she have?

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Get Side-Kick: Emergency Medicine or Quick Essentials: Emergency Medicine

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Answer: Primary Addison’s disease

Picture shows hyperpigmentation (she is caucasian). Here are some more.

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Selected Adrenal Conditions from

“QUICK ESSENTIALS: EMERGENCY MEDICINE“

ADDISON’S DISEASE= PRIMARY ADRENAL INSUFFICIENCY::  Mineralocorticoids out. Always consider if low BP unresponsive to fluid
Symptoms: Anorexia, N/V, abdo pain, F, fatigue, malaise, weakness, hyperpigmentation
Signs: Lethargy, confusion, coma, orthostasis, low BP, hyperpigmentation
Causes: Autoimmune, CA mets, TB, HIV, fungal, Meds(ketoconazole,rifampin,dilantin,megace,barbs)
Labs: Low Na: 88% >Eosinophilia, elevated K, low glu, cortisol < 20 1&2h p ACTH 250mcg test dose
Rx: D5NS, decadron 6mg(won’t interfere with cortisyn stimulation test).  NO: pressors

SECONDARY ADRENAL INSUFFICIENCY: More common than primary.  Mineralocorticoid axis OK
Sx/Sn: A, N, V, abdo pain, F, fatigue, CNS, weak.  No hyperpigmentation or dehydration
Causes: Steroids + stress or w/d:18mo later, pituitary, TB, sarcoid, CA, Sheehan’s, Idiopathic,lymphocytic
Lab: Potassium and sodium OK, glucose low, cortisol < 20 1&2h p ACTH 250mcg;
Rx:  D5NS, decadron 6mg (won’t interfere with cortisyn stimulation test).  NO: pressors

CONN’S DISEASE: Mineralocorticoid excess.
Sx/Sn:  Hypertension

CUSHING’S DISEASE: Glucocorticoid excess.
Sx/Sn: Weight gain, osteoporosis, weak, HTN, DM, chol, PUD, psych, eye, acne/hairy.  ID ŝ fever
Lab:  elevated WBC, low K, elevated eosinophils, elevated glucose

PHEOCHROMOCYTOMA:  HA, palps, sweat; HTN & OSVS, Hyperglycemia, tachy, tremor
W/u:  Urine metanephrines, CT abdo, MBIG scan
Rx: Phentolamine 5mg q 5min IV, phenoxybenzamin PO