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Case Report Brian Kurtz D.O. PGY-2 11/5/10

Case Report Brian Kurtz D.O. PGY-2 11/5/10. 19 y/o female presents to outpatient office with chief complaint of “passing out”

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Case Report Brian Kurtz D.O. PGY-2 11/5/10

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  1. Case ReportBrian Kurtz D.O. PGY-211/5/10

  2. 19 y/o female presents to outpatient office with chief complaint of “passing out” She reports multiple episodes of losing consciousness during the past year. These episodes are preceded by severe crampy abdominal pain, nausea and vomiting. She develops gray-ashen complexion. The symptoms have woken her from sleep, but have also occurred mid-day. No identified precipitating or mediating factors. They are not related to sitting/standing. She denies other preceding or associated symptoms of sweats or chills, headache, visual changes, incontinence, tongue biting, chest pain, palpitations, shortness of breath, URI, diarrhea, constipation, dysuria, or rash. She has no history of seizure activity or cardiac abnormalities She presented to Elmer Hospital with previously described symptoms recently with associated hypotension (BP 76/30). She was volume resuscitated and started on midodrine 5mg TID.

  3. PMH: migraine with aura Family hx: mother with multinodular goiter; grandmother with thyroid cancer Medications: Maxalt, Nexium, Compazine Recently started oral contraceptives, however symptoms began prior to this. She reports normal menstrual cycle before starting birth control. Allergy: sulfa Denies alcohol, tobacco, drug use Currently a nursing student.

  4. Diagnostic studies performed at Elmer: Na 138, K 3.9, CL 104, CO2 22, BUN 9, Cr 0.7, glucose 120, Ca 9.3 WBC 8.6, Hgb 13.9, Hct 40.3, Plt 253 LFTswnl, amylase 43, lipase 58 UA wnl

  5. EKG wnl, cardiac enzymes negative for acute MI Echo – normal LV fxn; mitral valve prolapse Currently wearing a Holter monitor CT head negative EEG – no seizure activity Urine drug screen negative

  6. Endocrine studies: Thyroid studies wnl Prolactin - 15 AM cortisol – 9.4

  7. Physical Exam at office visit: HR 80, BP 110/70; orthostatics negative Gen- AAOx3, resting comfortably HEENT – normocephalic; PERRL, EOMI; MMM Neck- No thyroid nodularity or tenderness CV- RRR, no M/R/G, no JVD, (+) click Resp- CTA b/l, no wheeze/crackles GI- soft, NT, ND, normal active bowel sounds Ext- no edema Neuro- CN 2-12 intact; no focal deficits; strength 5/5 b/l; sensation intact; DTRs 2/4 b/l Skin- no rashes or lesions

  8. Ddx: • Cardiac arrhythmia • Hypoaldosteronism • Pheochromocytoma- (NEJM Case 14 2010) • Carcinoid syndrome

  9. Adrenal Insufficiency • Causes of adrenal insufficiency: autoimmune (MC primary), adrenoleukodystrophy, infection (TB, fungal, HIV), hemorrhagic (Waterhouse-Frederichsen syndrome), metastasis, infiltrative(amyloid, sarcoid), exogenous steroids (MC secondary), sepsis/stress response • Symptoms: lethargy, nausea, vomiting, abdominal pain, hypotension Ddx: Cosyntropin test Give 0.25 mg of IV or IM Cosyntropin Measure aldosterone and cortisol before administration, 30 minutes later, and 60 minutes later. If no response = primary hypoaldosteronism If low am cortisol, and > 5mg/dL after stimulation = secondary hypoaldosteronism Treatment: IV fluids; IV hydrocortisone 100mg q6h

  10. Cosyntropin test: Cortisol 11:50am – 7.3mg/dL , 12:20 – 22.1mg/dL, 12:50 – 26.2mg/dL

  11. Pheochromocytoma • Tumor from chromaffin cells in adrenal medulla or sympathetic ganglia (paragangliomas). Produce epinephrine and norepinephrine. • 10% bilateral, 10% extra-adrenal, <10% malignant • Normally associated with elevated blood pressure; can rarely present with hypotension, as well as shock after trauma or surgery. • Paroxysmal headaches, sweats, palpitations, chest or abdominal pain, nausea, vomiting, anxiety • Cocaine use and clonidine withdrawal can mimic symptoms • Genetic disorders associated: MEN 2A and 2B, von Hippel-Lindau, Neurofibromatosis Type 1

  12. Dx: 24 hour urine metanephrines and urine free catecholamines; vanillylmandelic acid (less sensitive and specific) • Diagnosis more accurate if performed within 24 hours of crisis • Medications such as sympathomimetics, sinemet, and labetalol can influence test • If urine studies inconclusive, can measure plasma catecholamines

  13. Tx: alpha receptor blockade with phenoxybenzamine 10mg q12h, titrated upward; prazosincan also be used • Can add beta receptor blocker only after alpha blocker instituted • Surgery is definitive treatment; watch for intraoperative hypertension and treat with nitroprusside • 10% recurrence

  14. Carcinoid Syndrome Tumor can originate from appendiceal tip, small intestine (most common), stomach, rectum, or bronchial tissue Secretes serotonin and histamine Symptoms: flushing, abdominal pain, diarrhea, salivation, lacrimation, pellagra-like skin lesions, wheeze Can develop cardiac lesions on tricuspid valve and pulmonary stenosis, retroperitoneal fibrosis causing ureteral obstruction

  15. Dx: 5-HIAA, serotonin • Tx: SQ octreotide; 5-HT and histamine antagonists; interferon alpha; surgery

  16. References • Harrison’s Internal Medicine • Up-To-Date • MKSAP • NEJM 362:1815-23 May13, 2010. Case 14 – 2010: A 54-year-Old Woman with Dizziness and Falls. Samuels, Pomerantz, Sadow

  17. What do you think this patient has?

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