Addison’s disease

Patient Presentation:
A.F. a, 46 year old female patient arrived to the ER after becoming confused and incoherent to family and having a syncopal episode.  Upon arrival to the ER the patient was hypotensive at 75/45, tachycardic at 123, temperature of 100.3 and RR of 20.  Blood glucose was 56.  Per family account patient recently had a cholecystectomy that was indicated for patient’s severe abdominal pain, nausea, and vomiting.  Post-surgery patient continued to have the same complaints and condition deteriorated further with symptoms of fatigue and loss of appetite becoming more severe as reported by family.  

Differential list:
Infection/sepsis related to surgery, acute hypoglycemia, acute appendicitis, adrenal insufficiency

Diagnosis:
Blood cultures, CBC, and BMP were initially drawn.  IV was started with 0.9%NS to maintain blood pressure and heart rate.  5% Dextrose was also administered to normalize blood glucose levels.  CBC was within normal limits.  BMP results showed hyperkalemia (6.0 mM) and hyponatremia (127 mM).  Upon admittance to the hospital an endocrinologist ordered cortisol and ACTH levels drawn.  Cortisol level was 2.6 mcg/dL.  Levels less than 3.0mcg/dL are indicative of Addison’s disease.  ACTH levels were 60 pg/mL.  Normal ACTH levels are 50pg/mL.  Simultaneous low cortisol levels and elevated ACTH levels demonstrate adrenal insufficiency.

Treatment:
Initial treatment during acute adrenal insufficiency is to treat electrolyte imbalances and provide fluid replacement therapy to correct hypovolemia.  If adrenal crisis is suspected 100 mg of hydrocortisone every 6 hours should be started immediately.

Long term treatment for Addison’s disease includes daily replacement therapy of glucocorticoids and mineralocorticoids, dietary modification, and increased intake of glucocorticoids during times of acute stress.  A person with Addison’s disease will be prescribed 15-30 mg of hydrocortisone daily and administered in 2 or 3 divided doses with larger doses administered in the morning when more cortisol is needed. Fludrocortisone is used as replacement therapy for mineralocorticoids.  It is recommended that one’s intake of sodium should be at least 150 mEq per day and increased when there is excessive sweating or diarrhea.  In the case of Addisonian crisis that results in extremely low blood pressure, hypoglycemia, and high potassium, intravenous injection of hydrocortisone, saline, and dextrose is needed immediately.    

Outcome:
People with Addison’s disease should be able to live normal lives if adhering to daily replacement therapy treatment regimen.  Increased dosages of steroids will also be needed when their body is responding to increased stress.