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Interesting case 28 สงหาคม 2556
โดย ... นกศกษาแพทยชนปท 6 / อ.รงนภา ลออธนกล
ผปวยหญงไทยค อาย 61 ป Chief complaint: ไข 1 วนกอนมา รพ.
Present illness:
1 วนกอน - มไขต าๆ ไอ มเสมหะสขาวขน ไมมน ามก ไมมปสสาวะแสบขด ไมมคลนไสอาเจยน ไมมทองเสย ถายเหลว ตอมาไอเยอะขน รวมกบเหนอยมากขน จงไป รพช.
ทรพช. แรกรบพบ BP 100/60 mmHg, Temp. 38.6°C ตอมา ผ ปวยเหนอยมากขน หายใจเรวขน พบ HR 160/min. EKG เปน SVT แพทยจงให adenosine หลงจากนน EKG เปลยนเปน sinus rhythm rate 100/min. แตผ ปวยยงม BP 70/50 mmHg, pulse 120 /min แพทยได load NSS
3500 ml และให inotropic เปน Dopamine 1000 mg+ 5%DW 500
ml. IV drip และสงตวมา
Past history:
- Underlying COPD รบยาท รพช.เปนยาพน
- ปฏเสธประวตดมสรา และสบบหร
- ปฏเสธประวตการใช steroid
- ปฏเสธการแพยา แพอาหาร
- สขภาพกอนหนานแขงแรงด
Family history:
- ทกคนในครอบครว สขภาพแขงแรงด
Physical examination
• A Thai woman, Good consciousness, well co-operative • Vital Signs : BT 37.3 °C ,PR 60 /min, BP 100/60 mmHg, RR 18 /min • HEENT: not pale conjunctiva, no icteric sclerae, no lid lag, no lid
retraction, no thyroid gland enlargement, hyperpigmented gum • Heart : no active precordium, no heaving, no thrill, normal S1,S2 ,no
murmur • Lungs : Equal breath sound, crepitation both lungs • Abdomen : not distend, normoactive bowel sound, not tender, liver span
10 cm., spleen no dullness on percussion. • Extremities : no pitting edema, hyperpigmentation at both palmar crease
Hyperpigmented gum
Hyperpigmentation at both palmar crease
Physical examination
Neurological exam
– Good consciousness, follow to command
– Cranial nerve : pupil 3 mm. RTLBE, Full EOM, no facial palsy, normal gag reflex
– Motor normal tone, power gr. V all extremities
– Sensory pinprick sensation intact
– Reflex 2+ all extremities
– BBK absent
Problem List
• Shock
Differential Diagnosis
• Septic shock
• Hypovolumic shock
• Cardiogenic shock • Adrenal (crisis) shock
Investigation
• CBC
- WBC 17,100 /uL (N95.7%,LY3.2%,MO1.1%,EO0.0%,BA0.0%)
- Hb 9.9 ,Hct 30.8% MCV 76.4 RDW 16.1
- Platelet 227,000
Investigation
• Chemistry
– BUN 16.0
– Creatinine 1.27
– Sodium 134.9
– Potassium 3.38
– Chloride 106.2
– CO2 19.1
• Liver Function Test
– DB/TB 0.1/0.4
– AST/ALT 38/11
– ALP 55
– TP 6.0
– Albumin 3.2
– Globulin 2.8
– Cholesterol 103
• Serum Cortisol (ขณะท BP drop)
- Cortisol 1.9
• Serum L-Lactate
- L-lactate 4.8
• Thyroid Function Test – FT4 : 0.8 (0.6-1.6) – FT3 : 3.7 (2.39-6.79) – TSH : 0.22 (0.3-5.0)
• UA – Yellow ,cloudy
– Specific gravity 1.011
– pH 6.0
– Protein 1+
– Leukocyte 1+
– RBC 10-20 cell/HPF
– WBC 5-10 cell/HPF
– Squamous epithelium cell : negative
– Bacterial : Few cocci
– Mucous thread : Trace
Adrenal Insufficiency
Adrenal Insufficiency : Etiology Primary AI : Addison’s Disease
1. Autoimmune Disease
-APS -Isolated Autoimmune adrenalitis
2. Congenital - CAH
3. Infection - TB Histoplasma CMC
4. Vascular - Hemorrhage (meningococcemia) -1 Antiphospholipid synd. -Trauma
5. Metastatic
6. Drugs Ketoconazole Rifampicin
7. Infiltrative disease Hemochromatosis Amyloidosis
Adrenal Insufficiency : Etiology
Secondary AI HPA Axis dysfunction 1. Extrinsic -Exogenous Corticosteroid
2. Intrinsic
-Pituitary Tumor -Brian Tumor -Pituitary Apoplexy -Pituitary Irradiation -Pituitary Infiltration : TB, Actinomycosis, Sarcoidosis -Congenital isolated ACTH Deficiency
Clinical Manifestation
Primary adrenal insufficiency • hyperpigmentation, hyper K, vitiligo, adrenal
calcification, orthostatic hypotension, craving salt Secondary adrenal insufficiency • Pale skin not due to anemia, decrease libido and
impotence, DI, delayed puberty, loss of axillary or pubic hair
Both • Nausea, vomiting, diarrhea, hypoNa, orthostatic
hypotension, shock, anorexia, weight loss, hypoglycemia, lymphocytosis, normocytic anemia, tiredness, depression
www.medscape.com
Investigation
ACTH stimulation test
Laboratory Testing
Initial testing
• Measure early morning serum cortisol
If Cortisol ≥ 3 µg/dL
primary adrenal insufficiency less likely
However, if serious consideration
is given to this diagnosis, perform dynamic testing
Dynamic tests
• Insulin-induced hypoglycemia
• 250 μg ACTH stimulation test – 250 μg ACTH IV – Serum cortisol 0, 30 and 60 min – Peak cortisol ≥18 μg/dl exclude adrenal insufficiency
• 1 μg ACTH stimulation test – More sensitivity test in secondary adrenal insufficiency
Goal standard test
William Textbook of Endocrinology 11th edition
Primary or Secondary AI?
• ACTH level
If ACTH >100 pg/dL
Primary adrenal insufficiency
Imaging Studies
• MRI/CT based on stimulation testing
• If stimulation testing or absolute cortisol suggests adrenal failure – MRI/CT of adrenal glands
• If stimulation testing suggests pituitary failure – MRI/CT of pituitary
Management
Adrenal Crisis
• Required urgent diagnosis and management
• Blood for serum cortisol, renin, ACTH, chemistry
• Therapy initiated immediately
• Find precipitating cause and properly treated
Adrenal Crisis
• 1-3 liters of IV Fluid in 12-24 hr. based on volume status and Urine output – 0.9%NaCl
– 5%D/NSS – to correct possible hypoglycemia
• Glucocorticoid – Dexamethasone 4 mg IV bolus for no history of AI
– Hydrocortisone 100 mg IV bolus for 1° AI with high K
– Any preparation
• Taper over 1-3 days and change to an oral maintenance dose
Chronic AI
• 1˚ Chronic AI
– Replacement
• Glucocorticoid
• Mineralocorticoid
• Androgen
• 2˚ Chronic AI
– Replacement
• Glucocorticoid
Chronic AI
• Patient education
– The nature of hormonal deficit and the rationale for
treatment
– Maintenance med. And adjustment during minor illnesses
– When to consult a clinician
– When and how to injected a glucocorticoid for emergencies
Chronic AI
• Ideal glucocorticoid replacement therapy
– Mimic the endogenous cortisol rhythm
– Have little inter-individual variability in metabolism
– Be amenable to easy dose titration
– Minimize the risk of over treatment, resulting in iatrogenic Cushing’s syndrome
Chronic AI
• Prednisolone
– 5 mg oral OD – General dose
• Advantage
• OD dose
• Disadvantage
• More variable inter-individual metabolism
• Over-treatment
Chronic AI
• Monitoring dose
– Symptoms assessment
• Lowest dose that relieves sx.
• Avoid signs & symptoms of excess steroid : wt. gain, facial plethora, Cushing’s, osteoporosis
– Plasma ACTH
• Low normal or suppressed morning plasma ACTH from excessive glucocorticoid
Chronic AI
• Mineralocorticoid replacement
• In primary adrenal insuff.
• Fludrocortisone is drug of choice
• Usual dose 0.1 mg/day
• Monitor – orthostatic hypotension, blood pr. & pulse, serum K, plasma renin activity : upper normal range
Chronic AI
• Androgen replacement - DHEA
• Esp. Women : Mood & Quality of life
• Only women who have sig. impaired mood & sense of well-being despite optimal glucocorticoid & mineralocorticoid replacement
• Start dose : 25-50 mg/day 3-6 mo.
• Monitor S/S & adverse effect – If not sig. improve or have adverse eff. : discontinue
Chronic AI
• Consider in 2˚ AI
– Replacement of thyroid hormone without glucocorticoid can precipitate acute adrenal crisis
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