Thieves' Market

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Thieves' Market

• Christopher Russell M.D.
• West Virginia University
• 18 October 2008

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Case Presentation

• 77 yo female
• Brought in by her husband for confusion
• Slow to respond
• Answers were inappropriate to questions
• Poor PO intake past 4 days
• Decreased urine output and urine with a strong
  smell
• Acute dysphagia with solids and liquids

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• Past Medical/Surgical History
• Hypothyroidism
• Osteoporosis
• Osteoarthritis
• Seasonal allergies
• Hx of colon cancer s/p sigmoid resection in 2000
• Hysterectomy for benign bleeding

• Meds
• Levothyroxine
• Alendronate
• Loratidine
• Calcium

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• Social History
• Retired college nursing professor
• Lives with her husband
• No alcohol use
• Non-smoker
• No travel

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• Review of Systems
• Generalized weakness and fatigue
• No fevers or chills
• Weight loss 10 lbs in 4 months
• Feet felt numb
• Diffuse arthralgias
• No abdominal pain, nausea, vomiting, or diarrhea

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Physical Exam

• T 36.7oC
• BP 80/50
• P 86
• RR 16
• O2 Sats 96 RA
• Wt 43 kg

• Mild distress
• Slow to respond to questions/commands
• Oriented to person, not place or time
• Poor skin tugor
• Rhonchi bilaterally
• Hypoactive bowel sounds, nontender

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Labs

• 13 PMN 77
• 5.7 275 Lymph 12
• 37.3 Eos 2
• Mono 9

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Labs

• 125 98 40
• 128
• 4.9 15 1.5
• 7.316 28.6 138 14.8

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Urine Studies

• UA - pH 5, SG 1.015, blood/protein negative
• Urine osm - 486
• UNa - 64
• UCr - 63
• UK - 30
• UCl - 65
• FENa 1.2

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Labs

• Cortisol 9.3
• Cortisol 9 (s/p cosyntropin stimulation 0.25 mg)
• Renin 68.2 (lt3.4)
• Aldosterone lt2.5 (4-31)
• ACTH gt 1250 (lt46)

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• Final Diagnosis
• Addisons Disease
• Autoimmune Polyendocrine Syndrome Type II
  (Schmidts syndrome)

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Goals

• To learn about Addisons disease and United
  States history
• To become familiar with the autoimmune
  polyendocrine syndromes

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Types of endocrine disorders associated with
autoimmune polyendocrine syndrome type II

• Disorder Percent
• Adrenal insufficiency 100
• Autoimmune thyroid disease 70
• Type 1 diabetes mellitus 50
• Primary hypogonadism 5-50
• Diabetes insipidus lt1

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Pathway of Adrenal Steroid Synthesis
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• Treatment
• Order of treatment
• Screening
• Hypothyroidism
• Diabetes
• Addisons disease

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Conclusion

• Possible influence of Addisons disease on United
  States history
• Autoimmune polyendocrine syndrome type II
  consists of Addisons disease, hypothyroidism and
  type 1 diabetes
• When adrenal failure and hypothyroidism are
  diagnosed, treat the adrenal failure first

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References

• Nicholas JA, Burstein Cl, Umberger CJ, Wilson PD.
  Management of adrenocoritical insufficiency
  during surgery. AMA Arch Surg. 1955
  Nov71(5)737-42.
• Owen L. Diseased, demented, depressed serious
  illness in Heads of State. QJM. 2003
  May96(5)325-36.
• Nichols J. President Kennedys adrenals. JAMA.
  1967201115-116.

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• Kronenberg Williams Textbook of Endocrinology,
  11th edition.
• Eisenbarth GS, Gottlieb PA. Autoimmune
  Polyendocrine Syndromes. N Eng J Med
  20043502068-79.
• Ten S, New M, Maclaren N. Clinical review 130
  Addisons disease 2001. J Clin Endocrinol Metab.
  2001 Jul86(7)2909-22.