JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
CLINICAL CASE OF THE MONTH
New Onset Hypertension and Diabetes in a 24 Year-Old Man
Elizabeth Smith, MD, Catherine Pisano, Robert Richards, MD, Taniya DeSilva, MD, Fred Lopez, MD
INTRODUCTION
The day prior to his follow-up, he was involved in a motor vehicle accident. He was ambulatory at the scene with no loss of consciousness. He was brought to the ED by EMS, where he continued to endorse all complaints from his prior ED visit, with additional complaints of midline neck pain and intensified generalized abdominal pain. His past family history was relevant for a father with sickle cell disease and a grandfather with type 2 diabetes mellitus and hypertension. He denied any past surgeries, use of illicit substances, or use of alcohol. He was a current every-day smoker with a three pack-year history. His only medication was his recently prescribed metformin, and he denied any allergies. His vitals at presentation were: blood pressure 170/108 mmHg, pulse 88/min, respiratory rate 22/min, temperature 99.2 o F, and BMI 37.6 kg/m 2 . Physical examination revealed moon facies (Image 1), an increased dorsocervical fat pad (Image 2), and oropharyngeal candidiasis. The patient was noted to be tender to palpation in the left upper quadrant, with diffuse abdominal striae and central obesity (Image 3). The patient also had striae over both upper extremities, pretibial edema bilaterally, onychomycosis, and tinea pedis bilaterally. Laboratories revealed a glucose of 855 mg/dL [69-99 mg/dL], potassium of 2.7 Mmol/L [3.6-5.2 Mmol/L], hemoglobin A1c of 14.2%, triglycerides of 493mg/dL [<150mg/dL], and ametabolic alkalosis. In the ED, a computed tomography (CT) scan of the cervical spine was unremarkable. A CT scan of the abdomen and pelvis demonstrated bilateral avascular necrosis of his femoral heads as well as bilateral adrenal hyperplasia. The patient was then admitted for further evaluation and management. A random cortisol level was > 60 mcg/dL [3-16 mcg/dL]. The patient was started on long acting insulin in addition to sliding scale insulin for his hyperglycemia, and losartan for his elevated blood pressure. Endocrinology was consulted and additional lab tests were ordered. A 24-hour urine cortisol returned at 9205 mcg/dL [< 50 mcg/dL], an ACTH level returned at 245 mcg/dL [3- 60 mcg/dL], and a 24 hour urine 5-HIAA level was within normal limits. In addition, a low dose dexamethasone suppression test was performed, which failed to correct the patient’s cortisol, the level returning at 55 mcg/dL.
Pituitary adenomas are classified based on size (macroadenomas > 1 cm), immunohistochemistry, electron microscopy, and hormone functional status. Overall, pituitary adenomas (including micro and macroadenomas) have a prevalence of 16.7%, making them a relatively common pathological finding. Pituitary macroadenomas are even less common, with a prevalence of 0.2%. Furthermore, ACTH secreting tumors are found in only 4.9% of patients with pituitary adenomas. 1 An ACTH secreting pituitary adenoma results in Cushing’s disease, which is a hypersecretion of ACTH from the adenoma itself. In general, this hypersecretion leads to a cushingoid appearance, which is characterized by central obesity, moon facies, proximal muscle weakness, easy bruising, striae, hirsutism, and an increased dorsocervical fat pad. It is often found in conjunction with glucose intolerance, polyuria, polydipsia, hypertension, hypokalemia, metabolic alkalosis, and renal calculi. 2 Cushing’s disease is the leading cause of ACTH dependent Cushing’s syndrome, occurring in 65-70% of patients. 3 Early diagnosis and treatment of this curable disease can significantly decrease morbidity and mortality of these patients; therefore, despite its rare occurrence, it should remain a differential diagnosis for patients presenting with the aforementioned symptoms.
CASE PRESENTATION
A 24 year-old man with a past medical history of asthma and sickle cell trait presented to the emergency department (ED) with complaints of polyuria, polydipsia, dry mouth, and blurry vision for two weeks. He complained of a white adherent material on the roof of his hard palate. Additionally, he described a three year history of 30 pound weight gain despite not changing his diet or lifestyle. He also endorsed generalized abdominal pain and malaise. He was noted to have an elevated blood pressure of 172/111 mmHg, as well as an elevated blood glucose of 565 mg/dL and a BMI of 36.5 kg/m 2 . In the ED, the patient was diagnosed with new onset diabetes mellitus. He was given intravenous fluids, a prescription for metformin, a blood glucometer, diabetic diet education, and a follow-up visit with a primary care provider.
J La State Med Soc VOL 170 JANUARY/FEBRUARY 2018 25
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