5.0 of 5 Ratings
A 42-year-old Caucasian woman presents to the emergency department with complaints of progressive weight loss, dizziness, nausea, and vomiting over the last several months. She returned from a 2-week international business trip 6 months ago where she reports being ill with a fever, diarrhea, and a cough. Her temperature is 97.7°F (36.5°C), blood pressure is 114/64 mmHg, pulse is 105/min, respirations are 72/min, and oxygen saturation is 99% on room air. Physical exam is significant for the finding in Figure A. Initial laboratory studies are ordered as seen below.Serum:Na+: 139 mEq/LCl-: 100 mEq/LK+: 6.3 mEq/LHCO3-: 15 mEq/LBUN: 20 mg/dLGlucose: 66 mg/dLCreatinine: 1.1 mg/dLCa2+: 10.2 mg/dLWhich of the following is the most likely underlying etiology of this patient's symptoms?
Select Answer to see Preferred Response
A 49-year-old man presents with 3 months of generalized weakness. He has had a chronic cough and a 20 pound unintentional weight loss over the past 6 months. He has a medical history significant for high blood pressure, hyperlipidemia, and seasonal allergies with no prior surgical history. He has no history of tobacco use. He moved from India 7 years prior to presentation. He currently lives in Oregon and has not left the west coast since moving. His temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 76/min, and respirations are 16/min. His physical exam is significant for hyperpigmentation of the oral mucosa and temporal muscle wasting. Radiography of the abdomen demonstrates bilateral adrenal calcifications. Laboratory values are as follows:Serum:Na+: 130 mEq/LCl-: 96 mEq/LK+: 5.2 mEq/LHCO3-: 24 mEq/LMorning cortisol: 2 ug/dL 30-minute cortisol during cosyntropin test: 8 ug/dL (normal > 18 ug/dL)Morning adrenocorticotropic hormone (ACTH) concentration (serum): 80 pg/mL (normal 10-60 pg/mL)Which of the following is the most appropriate next step in management?
Bilateral adrenalectomy, prednisone, and fludrocortisone
Hydrocortisone and immunoglobulin therapy
Rifamycin, isoniazid, pyrazinamide, ethambutol, and hydrocortisone therapy