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MEDICAL

EMERGENCIES

CASE 1

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The Case

Mang Tibo, a 55 year old male was diagnosed 6 years

ago to have pulmonary tuberculosis but was only able to

complete months anti!"och#s treatment$ Two years ago

he noticed progressive weight loss$ %e e&perienced

asthenia most o' the time$ %yperpigmentation developedover the elbows and palm creases$ A day prior to

admission, he e&perienced ill!de'ined abdominal pain with

diarrhea$ %e was brought to a nearby lying!in clinic and

was started on intravenous 'luids$ %owever, he was notedto be persistently hypotensive in spite o' 'luid

replacement$ %e was trans'erred to MC(!)*TM)

%ospital$ +-./0/, %2-150min, 22-3/0min$

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Salient )eatures

• Male, 55 years old

• *iagnosed T+ 6 years ago

• Completed months o' Anti!"och#s treatment

•

4eight loss years ago•  Asthenia most o' the time

• %yperpigmentation on elbow and palm creases

• %ad ill!de'ined abdominal pain

• *iarrhea

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Salient )eatures

• ersistent %ypotensive inspite administration o'

)luids

• *ecreased + o' ./0/

•

ncreased heart rate o' 150min• ncreased respiratory rate o' 3/0min

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DIFFERENTIAL DIAGNOSIS

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 Adrenal Crisis

• 7i'e!threatening

• E&acerbation o' adrenal insu''iciency leading to

insu''icient cortisol ! a hormone produced by the

adrenal glands

• The patient#s history o' pulmonary tuberculosis

predisposed him to develop primary adrenal

insu''iciency$

• Since he was not able to continue his anti!"och#s

treatment 'or 6 months, he might have progressed to

developing adrenal crisis$

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 Adrenal Crisis

Suggestive of Adrenal Crisis Not Suggestive of Thyrotoi!osis

Diarrhea 8one

A"do#inal $ain

%y$otension&rogressive 'eight loss

S(in $ig#entation

Ta!hy$nea

Ta!hy!ardia

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Thyroto&icosis

• This is a state when there is e&cessive 9uantity

o' endogenous or e&ogenous thyroid hormone$

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Thyroto&icosis

Suggestive of

Thyrotoi!osis

Not Suggestive of Thyrotoi!osis

)ea(ness *asthenia+  Abdominal pain

&rogressive 'eight loss %yperpigmentation o' palmar creases andelbows

Diarrhea %ypotension

Ta!hy!ardia *%R ,-.

"eats/#in+

Tachypnea :;<

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&AT%O&%0SIOLOG0

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T+ n'ection :6 years ago<

%ematogenous spread

7odge to adrenal glands

*estruction o' adrenal glands

 Adrenals 'ail to secrete its

hormones

*ecreased

mineralocorticoids

%!!A a&is sense

decrease in adrenal

hormones :cortisol<

*ecreased

glucocorticoids

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*ecreased mineralocorticoids

*ecreases 8a

=

 reabsorption

*ecreased ability to concentrate

urine

*ecreased circulatory volume

%ypovolemia :+ ./0/mm%g<

ncreased %2 :15 beats0min<

ncreased 22 :3/ breaths0min<

ncreased

serum "=level

ncreased

> motility

 Abdominal

pain

*iarrhea

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%!!A a&is sense decrease in

adrenal hormones :cortisol<

8egative 'eedbac? stimulation

ncreased ACT% production by >

igmentary changes occur due to

 ACT%#s intrinsic MS% activity

%yperpigmentation o' elbow and

palmar creases

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*ecreased glucocorticoids

*ecreased

appetite

*ecreasedgluconeogenesis

*ecreased

C%@8 synthesis*ecreased induction

o' insulin secretion

rogressive

weight loss*ecreased

energy

production

 Asthenia

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T%AN1 0O23