Case 15 Gastroenterology

Hyperpigmentation

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

A 44 y/o man is admitted with acute abdominal pain, nausea, vomiting, and diarrhea. HR 130, BP 90/52. You walk into the room to meet the patient. What do you notice? This should generate at least one hypothesis.

Clue 2

You ask the patient for an old photograph for comparison. His wife pulls out her phone and produces this picture (B) taken about 10 years prior. Pt reports darkening of skin over an 8 year period (for which he saw several clinicians). What conditions are you considering?

Clue 3

Let’s consider the hypotension. Physical examination is critical in determining which “category” of hypotension we are dealing with. How can physical exam help

Clue 4

In this case, JVP is low and extremities are warm.This pattern is characteristic of distributive hypotension. Do any of the conditions listed there match your initial hypothesis?

Clue 5

A confirmatory test is your next step. Serum cortisol is 4.4 ug/dL 60 minutes after a 250 ug injection of ACTH. (Normal adrenal function is established when serum cortisol level is >18 ug/dL after ACTH stimulation.)

Clue 6

You have now confirmed the diagnosis of adrenal insufficiency. The next question is, is it ACTH-dependent or ACTH-independent? A plasma ACTH level is necessary to make this determination. But based on your physical exam, you already know the answer.

Clue 7

Plasma ACTH level (drawn prior to the stim test) is 872 pg/mL (reference range 10-60 pg/mL).

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