acid-base disorder were concerning for adrenal insufficiency and hypoaldosteronism. Workup of aldosterone, cortisol, and renin labs revealed significantly low cortisol and aldosterone with elevated renin and ACTH. Subsequent ACTH stimulation tests confirmed a primary adrenal insufficiency. A CT abdomen/pelvis was obtained which showed small bilateral adrenal glands with calcifications showing prior granulomatous infiltration. Considering biapical disease in the setting of granulomatous infiltration, an infectious etiology was pursued despite initial negative testing. Patient was eventually found to be TB positive via QuantiFERON gold testing. Given the imaging
findings with his active infection, the etiology of his adrenal insufficiency and hypoaldosteronism was believed to be secondary to TB infection. The patient was ultimately treated with RIPE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) therapy in addition to steroid replacement with hydrocortisone and fludrocortisone for primary adrenal insufficiency (PAI). Discussion: Though there is a common association between TB and PAI, this case illustrates how TB can be difficult to diagnose, particularly if the first presentation manifests as extrapulmonary disease instead of the classic pulmonary symptoms that are usually seen in active TB infection.
NEVER TURN A BLIND EYE IN DKA Sofia Beg, Rohan Lal, Nadish Ravindran; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Diabetic ketoacidosis is commonly treated in the critical care setting, however mucormycosis is a rare infectious complication of uncontrolled disease that is less frequently diagnosed. Case: A 42 year old female with bipolar disorder, depression, and schizophrenia presented with two weeks of worsening lethargy, altered mentation, and eventual syncope. Patient was found to be hyperglycemic in the setting of metabolic anion gap metabolic acidosis and elevated beta-hydroxybutyrate consistent with Diabetic Ketoacidosis (DKA). She was initially treated for DKA associated with coma with insulin and intravenous fluids, which improved her hyperglycemia and metabolic acidosis. During her admission, leukocytosis was persistently worsening, prompting evaluation of an infectious etiology. Despite broad spectrum antibiotics and antifungal treatment, the leukocytosis continued to increase. As the patient’s mentation improved, she complained of isolated right eyelid swelling, but denied other complaints. Symptoms did not improve with conservative measures. The case was discussed with the
ophthalmology team, who recommended an MRI head/orbit which showed paranasal sinus mucosal thickening with fluid in bilateral sphenoid and right maxillary sinuses, in addition to multiple small infarcts in the right cerebral hemisphere and occlusion of the right internal carotid artery. This raised high concern for extensive rhinoorbital mucormycosis infection therefore treatment with Amphotericin B was initiated. Patient continued to have declining unilateral vision loss while on therapy. She was transferred to a facility with ENT services available, however deemed a poor candidate for debridement due to extent of infection at time of discovery. Given the aggressive nature of her infection, the decision was made to discharge the patient to hospice care. Discussion: This case demonstrates the rapidly progressive nature of a rare but commonly associated complication of uncontrolled diabetes and the importance of a multimodal specialist approach to diabetes management. Prompt diagnosis and management in this case required assistance from ophthalmology, endocrinology, and ENT specialists.
RIGHT ATRIAL MASS Ishrat Gillani, Gurjit Brar, Vishal Vyas; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: In patients with atrial fibrillation the most common finding is a left atrial thrombus, however in 3-6% of cases we often see right atrial appendage thrombi.
Case: A 69-year-old male lost to follow up presented with complaints of dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and bilateral lower extremity edema. History is significant for persistent atrial fibrillation with restoration to normal sinus 14
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