A 17 YEAR OLD BOY WITH ADRENAL INSUFFICIENCY

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This is a case of a 

17 year old boy resident of Nalgonda,  student by occupation came to the casuality with the chief complaints of -

• Giddiness since 1week
• SOB on exertion  with nausea and vomiting since 2days
• Fever since 2 days

History of presenting illness- 

Patient was apparently asymptomatic 1week back,  then he developed giddiness which was sudden in onset on standing and sitting posture with no aggravating factors and is  relieved on consumption of food. 

Later he developed shortness of breath 2 days ago which aggravated on exertion and relieved on rest 

Fever with chills and rigors moderate, associated with body pains since 2 days

Nausea and vomiting since 2 days, non bilious, non projectile,contains food particles which aggravated on consuming food.

PATIENT HISTORY-

On 28/05/2021

Patient presented with chief complaints of

Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year .

Purple stretch marks over abdomen ,lower back ,upper limbs ,thighs since 1 year .

Abdominal distension and facial puffiness since 6 months.

Pedal edema since 3 months.

Lower back ache since 3 months

Weight gain and decreased libido since 3months.

Pt was apparently asymptomatic one and half year ago , then he slowly developed erythematous round leisons which are annular shaped and itchy all over abdomen , upper limb ,groin and inner thigh region 

He visited local RMP where he prescribed ayurvedic medications and creams and tablets  (composition unknown) which he used it for 1-2 months . 

Leisons reduced a bit after using medications .

 2 months later he developed multiple hyper pigmented plaques over lower limbs, abdomen , for which he again visited same place and used ayurvedic oils over the lesions.

He also used clobetasol ointment over the leisons for approximately 1 year all over the body. 

Then he started noticing pink striae over his abdomen first 1 year ago and later on back and over arms,which were gradually increasing in size .

Later he visited a hospital and used miconazole and luliconazole ointments. He used clobetasol ointment all over the leisons for long time .

He started noticing abdominal distension and facial puffiness ,weight gain, but never visited any hospital.

Later he developed pedal edema and low back ache since 3 months .

He then consulted a dermatologist who advised to consult physician and prescribed monteleukast , itraconazole tablets, luliconazole ointment for tinea corporis.

He stopped all medications one month ago and visited our opd with complaints of pink striae and easy fatigue ,weakness and low back ache .

His brother also gave history of pt being moody and feeling of low self esteem due to multiple leisons. He also complaints patient wouldn't step out of house and always stays indoor and wouldn't interact with others .

No complaints of chest pain ,sob , palpitations and decreased urine output

No other negative history.

He has a h/o allergy to eggs and brinjal .

ON EXAMINATION 

Patient was c/c/c 

Well built and well nourished

BMI- 20.51 kg/sq m

Pedal edema present - pitting type extending upto knee.

Abdominal distension present.

Moon face, pink striae noted over anterior abdominal wall and on lower back ,on upper arms and thighs. Thick skin

Poor healing noticed over leg ulcers and easy bruising noted . Acne over face 

Acanthosis nigrans noted over neck and pad of fat present 

GYNAECOMASTIA PRESENT .

Sparse scalp hair 

On Skin examination - 

Multiple itchy erythematous annular leisons noted all over abdomen , upper limb ,groin and inner thigh region .

Multiple hyperpigmented plaques noted over bilateral lower limbs .

Dermatologist's opinion for tinea corporis was taken where they advised 

Ointment amlorfine 

fusidic acid cream.

saline compress over leisons

Opthalmologist opinion was taken to look for visual acuity and cataract and was advised for follow up

On 30/5/21

Pt was advised to get fasting 8am serum cortisol levels and was planned to start on low dose steroids to avoid adrenal crisis.

8AM S CORTISOL LEVELS - 0.46 mcg/dl ( very low) .

In view of LVH pt was started on tab TELMA 20 mg od .

On 3/6/21 - 

ACTH STIMULATION TEST WAS DONE .

BY INJECTING 0.4 ML OF ACTOM PROLONGATUM INJECTION (ACTH) INTRA MUSCULAR at 7am 

1 HR LATER FASTING SERUM CORTISOL SAMPLE WAS SENT .

VALUE - 0.73 mcg/dl 

(Indicating there was HPA AXIS suppression and pt was started on TAB HIZONE 15 mg per day in three divided doses at 8am ,12 pm and 4 pm.)

He was diagnosed to have 

IATROGENIC CUSHINGS SYNDROME

SECONDARY TO TOPICAL CLOBETASOL APPLICATION ALL OVER BODY FOR APPROXIMATELY ONE YEAR.

TINEA CORPORIS

DENOVO HTN .

On 25/6/21

Symptomatically improved , pedal edema subsided.Striae were pale in color and were subsiding.

In view of low back ache he was advised.:

Tab Shelcal 500 OD and Tab Vit D 3 Od.

Tab ULTRACET /PO/SOS.

ON 5/07/21

 Patient complained of new ring lesions over legs.

 Pus discharge over abdominal striae with erythematisation

Was given

 

1. TRETIN GEL 0.05 % L/A OD X 2 weeks
2. TAB ATARAX
3. AMOROLFINE CREAM 
4. CAP AMOXICLAV
5. FUSIDIC CREAM

In July 2021

Patient tested positive for COVID 19 was  advised home isolation and PCM 650 Mg /po /tid x 5 days . 

He was advised to continue tab hizone tablets

He recovered from COVID within one week . 

On 06/8/21

BP- 170/100 - TELMA DOSE WAS INCREASED TO 40 MG OD.

PR - 88bpm.regular , normovolemic.

Wt- 69 kg 

Abdominal girth - 96cm

Pt complained of excoriation over striae and appearance of erythematous macules over abdomen whenever he takes food he is allergic to. 

They started him on Tab Itraconazole 100 mg bd for 2 weeks. And lulifin cream and tab levocitrixine 5mg od.

Complained of depressed mood , pt not going out due to social stigma. Psychiatric counselling was given .

0N 20/8/21

 In the view of constant low back ache , MRI LS SPINE WAS done with whole soine screening .

which showed lumbar epidural lipomatosis .

ON 24/8/21 -

Pt developed painful swelling and redness of right lower limb along with intermittent fever - DIAGNOSED TO HAVE 

RIGHT LOWER LIMB CELLULITIS . 

Pt was admitted and was given IV AUGMENTIN for 5 days and MGSO4 dressings were done .

In september 

complaints of weight gain , but striae reduced and patient attender was giving history of patient having low mood and constantly being at home and not doing any exercise . 

TAB HISONE dose was reduced to 5 mg /day.

On 23/ 11/21

c/o increasing striae and abdominal distension since one month.

c/o diminished vision 

weight gain present -76kg 

As his blood pressure is uncontrolled and ECG having LVH - the dose of TAB TELMA A 40/5 mg OD.

PERSONAL HISTORY-

occupation -student

Mixed diet

appetite -normal 

bowel and bladder - Normal

no addiction 

FAMILY HISTORY - 

His father has history of allergy 

PHYSICAL EXAMINATION-

No pallor, icterus, cyanosis, clubbing, lymphadenopathy 

VITALS-

temperature - afebrile 

pulse rate - 80 bpm 

RR - 12 cpm 

BP - 80/50 mm hg 

SPO2 - 98 on RA 

GRBS - 117.mg %

SYSTEMIC EXAMINATION-

CVS- S1 ,S2 heard ,no murmurs

RS - BAE +

P/A - soft ,non tender 

CNS -

Speech - normal  

Power- 

• U.L - 5/5 
• L.L - 3/5 at presentation in opd now 4/5

Tone- normal

Reflexes- 

• KNEE  + 
• BICEPS  + 
• TRICEPS +
• ANKLE  + 
• BRACHIORADIALIS + 
• PLANTAR - withdrawal

PROVISIONAL DIAGNOSIS-

Adrenal crisis 

Distributive shock secondary to adrenal insufficiency.

TREATMENT -

1)Inj norad 2amp in 46ml NS infusion @ 0.02mcg/kg/min if BPis low 

2)Inj hydrocortisone 100mg/iv/od

3)Inj pantop 40mg/iv/od

4)Inj zofer 4mg/iv/tid

5)IVF NS,RL,DNS-100ml/hr

6)BP charting

PR/Spo2/Temp charting

GRBS 8th hrly.

I would like to credit Dr. K. Vaishnavi ma'am for allowing me to access relevant information regarding the case.

Here's the link to Vaishnavi ma'am's blog:

http://karnativaishnavi.blogspot.com