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Aldosteronoma
6%
1/18
Autoimmune adrenalitis
39%
7/18
SIADH
0%
0/18
Tuberculosis
17%
3/18
Viral gastroenteritis
33%
6/18
Select Answer to see Preferred Response
This patient has adrenal insufficiency (Addison disease or autoimmune adrenalitis) given her weakness, fatigue, nausea, vomiting, hypotension, tachycardia, hyperkalemia, and metabolic acidosis. Primary adrenal insufficiency is characterized by an elevated plasma ACTH, a decreased aldosterone, possible hyponatremia, hyperkalemia, hypoglycemia, and a metabolic acidosis. Clinical manifestations of adrenal insufficiency can include skin hyperpigmentation, nausea/vomiting, fatigue, weight loss, orthostatic hypotension, fatigue, and myalgias/arthralgias. A cosyntropin stimulation test may confirm the diagnosis of adrenal insufficiency, regardless of the particular etiology. Patients will often need lifelong glucocorticoid and mineralocorticoid replacement. Figure A demonstrates the classic hyperpigmented skin in adrenal insufficiency which occurs secondary to increased pro-opiomelanocortin levels which are released in response to the increased CRH and ACTH release. Incorrect Answers: Answer 1: Aldosteronoma would present with hypertension, hypokalemia, and a metabolic alkalosis. Treatment involves removing the aldosteronoma. Answer 3: SIADH presents with hyponatremia and production of a small volume of concentrated urine. Patients may also present with hypertension. Answer 4: Tuberculosis is the most common cause of adrenal insufficiency worldwide; however, it is relatively rare in the United States. This woman's travel puts her at risk for a tuberculosis infection; however, her mild symptoms and absence of exposure, night sweats, and weight loss make this a less likely diagnosis. Answer 5: Viral gastroenteritis may have been the initial diagnosis this patient had given her viral illness. However, diarrhea typically causes hypotension and a metabolic alkalosis/hypokalemia secondary to increased activation of the renin-angiotensin-aldosterone system. Bullet Summary: Autoimmune adrenal insufficiency presents with fatigue, weakness, nausea, vomiting, hypotension, and hyperkalemia with a metabolic acidosis.
4.5
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