Aidey
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I would hesitate to call it Cushing's Disorder since that is caused by a specific thing, and we have no idea what is causing it yet. He definitely has some sort of hypogonadism going on.
Life is hard.
- Thread starter Veneficus
- Start date
A trip to the ED, and beyond:
ED tests included:
a head and abd CT. 3 micro infacts in the head scan
abd was normal
cxr showed cardiomegaly
CHM 12:
comprehensive metabolic
glucose: 130mg/DL
calcium 10 mg/dl
albumin 4.2gm/dl
protein 6.4
sodium 184 meq//L
potassium 4.3
co2 32/ meq/l
chrolride 116 Meq/l
BUN 14mg/dl
creatine .6mg/dl
ALP 211 u/L
ALT 66 u/l
AST 56 u/l
Billirubin direct .9
total: 1.9
cardiac markers:
trop I:ng/ml .11
trop T .22
myoglob: 101
ck: u/l176
ck mb: 7
Heme:
RBC 5.6 m/ul
WBC 12 K/mm3
HGb 17
hct 50%
ABG:
PH 7.33
paco2 40
pao2 80
hc03 98%
BE -1
hco3 22 meq/l
Pt was admitted straight to cardio (where i first saw him) with the following significant findings:
Cardiac echos (transesoph and transthoracic)
Showed dialated cardiomyopathy with tricuspid, mitral regurg, and Septal Anterior Motion. (SAM)
(I don't remember the dimentions or % regurg, they were very large)
Ejection Fraction calculated: 45%
Pt able to walk 322 meters without difficulty.
Endocrine consult:
cortisol:
morning: 30mcg/dl
afternoon: 13 mcg/dl
dexameth test: Normal ACTH
basline cortisol
Answers to your questions:
Well, since I'm playing doctor... What do his hands look like? Any blunting or rounding of the metacarpals?
Not to any appreciable degree
Adiposogenital dystrophy? Possibly secondary to tumor on the hypothalmus?
Abnormal head CT findings detailed, no AD.
Let me whip out my portable radiology suite while I'm getting that endocrine consult.
Endocrine consulted, but it took a few days to work this out.
I had also thought diabetes insipidus when I first started working this through, but I'm not entirely sure
Simply, no.
What does his EKG look like when he is in sinus?
Is there a specific detail past what I already mentioned you are looking for? I am not sure what you are asking.
How long was he using steroids when he was on the wrestling team?
patient reliably denies.
Can the pt remember how long he has been hairless
always
Tinnitus? Visual disturbances? Vertigo?
Not reported
I think he's visiting the ladies of the night because they're the only chicks he can get alone with and probably not consummating his relationships with them.
Sexual function reported as normal in physical findings. Pt. was very reliable in all interviews.
Any further qestions or thoughts welcomed final DX tomorrow night.
ED tests included:
a head and abd CT. 3 micro infacts in the head scan
abd was normal
cxr showed cardiomegaly
CHM 12:
comprehensive metabolic
glucose: 130mg/DL
calcium 10 mg/dl
albumin 4.2gm/dl
protein 6.4
sodium 184 meq//L
potassium 4.3
co2 32/ meq/l
chrolride 116 Meq/l
BUN 14mg/dl
creatine .6mg/dl
ALP 211 u/L
ALT 66 u/l
AST 56 u/l
Billirubin direct .9
total: 1.9
cardiac markers:
trop I:ng/ml .11
trop T .22
myoglob: 101
ck: u/l176
ck mb: 7
Heme:
RBC 5.6 m/ul
WBC 12 K/mm3
HGb 17
hct 50%
ABG:
PH 7.33
paco2 40
pao2 80
hc03 98%
BE -1
hco3 22 meq/l
Pt was admitted straight to cardio (where i first saw him) with the following significant findings:
Cardiac echos (transesoph and transthoracic)
Showed dialated cardiomyopathy with tricuspid, mitral regurg, and Septal Anterior Motion. (SAM)
(I don't remember the dimentions or % regurg, they were very large)
Ejection Fraction calculated: 45%
Pt able to walk 322 meters without difficulty.
Endocrine consult:
cortisol:
morning: 30mcg/dl
afternoon: 13 mcg/dl
dexameth test: Normal ACTH
basline cortisol
Answers to your questions:
Well, since I'm playing doctor... What do his hands look like? Any blunting or rounding of the metacarpals?
Not to any appreciable degree
Adiposogenital dystrophy? Possibly secondary to tumor on the hypothalmus?
Abnormal head CT findings detailed, no AD.
Let me whip out my portable radiology suite while I'm getting that endocrine consult.
Endocrine consulted, but it took a few days to work this out.
I had also thought diabetes insipidus when I first started working this through, but I'm not entirely sure
Simply, no.
What does his EKG look like when he is in sinus?
Is there a specific detail past what I already mentioned you are looking for? I am not sure what you are asking.
How long was he using steroids when he was on the wrestling team?
patient reliably denies.
Can the pt remember how long he has been hairless
always
Tinnitus? Visual disturbances? Vertigo?
Not reported
I think he's visiting the ladies of the night because they're the only chicks he can get alone with and probably not consummating his relationships with them.
Sexual function reported as normal in physical findings. Pt. was very reliable in all interviews.
Any further qestions or thoughts welcomed final DX tomorrow night.
Aidey
Community Leader Emeritus
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Were any hormone levels done?
Am I correct in thinking that you meant 3 micro infarcts?
Well, that bloody well doesn't help. Outside of the heme values there are only about 5 normal values.
Am I correct in thinking that you meant 3 micro infarcts?
Well, that bloody well doesn't help. Outside of the heme values there are only about 5 normal values.
cortisol levels were normal, aldosterone levels grossly elevated, and adrogen levels depressed. Sorry typed in so many lab values I missed them.
Yes, 3 micro infarcts, I still cannot type or spell
and I did mention that the lab values just complicated the matter.
FrostbiteMedic
Forum Lieutenant
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Me thinks that I am going to have to leave this one to the more learned of my esteemed collegues on this site....or else I need to call Dr. House....
Aidey
Community Leader Emeritus
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Where were the micro infarcts?
So, just to make sure I've got this right, he has never had body hair, but he is able to get an errection and ejaculate? You said genital size is small, is is just small or are we in micropenis territory? (Yes, that is the medical term before anyone asks)
How is his voice pitch? Can he smell? Any vision issues? Did they do a d-dimer or VQ?
So, just to make sure I've got this right, he has never had body hair, but he is able to get an errection and ejaculate? You said genital size is small, is is just small or are we in micropenis territory? (Yes, that is the medical term before anyone asks)
How is his voice pitch? Can he smell? Any vision issues? Did they do a d-dimer or VQ?
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Aidey
Community Leader Emeritus
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Ok, after about 8 hours of research I think I've got everything covered (very slow night @ work).
I was able to account for all the signs and symptoms with 3 disorders.
1. Endocarditis secondary to dental caries
That accounts for the caries, swollen tonsils, dilated cardiomyopathy, elevated cardiac enzymes, slightly elevated white count, and the micro infarcts (clots from broken off bacteria colonies).
2. Past alcoholism
Accounts for the LFTs, low protein and albumin, edema and high calcium.
It also explains the very strange endocrine results. Cortisol binds to protein in the blood, so hypoprotienemia can cause false negatives when testing for elevated cortisol. Because there is no protein for the cortisol to bind to, even if the cortisol is really there.
3. Congenital adrenal hyperplasia
I'm not sure what type, but it accounts for the hyperaldosteronism and the low androgen. I am assuming the cortisol is high, and the low protein caused a false result.
So this covers those abnormal labs, the Cushing's like symptoms, the high glucose ( I assumed fasting labs), the high sodium, the HTN, the lack off body hair, the smaller penis and testes (that still work) and the gynomastica.
So, am I in the ballpark? The staium? The right sport? lol
I was able to account for all the signs and symptoms with 3 disorders.
1. Endocarditis secondary to dental caries
That accounts for the caries, swollen tonsils, dilated cardiomyopathy, elevated cardiac enzymes, slightly elevated white count, and the micro infarcts (clots from broken off bacteria colonies).
2. Past alcoholism
Accounts for the LFTs, low protein and albumin, edema and high calcium.
It also explains the very strange endocrine results. Cortisol binds to protein in the blood, so hypoprotienemia can cause false negatives when testing for elevated cortisol. Because there is no protein for the cortisol to bind to, even if the cortisol is really there.
3. Congenital adrenal hyperplasia
I'm not sure what type, but it accounts for the hyperaldosteronism and the low androgen. I am assuming the cortisol is high, and the low protein caused a false result.
So this covers those abnormal labs, the Cushing's like symptoms, the high glucose ( I assumed fasting labs), the high sodium, the HTN, the lack off body hair, the smaller penis and testes (that still work) and the gynomastica.
So, am I in the ballpark? The staium? The right sport? lol
*sighs* On House, this is never the answer, but it seems to match many of the physical findings (as one would expect it to)... So...
What about lupus?
I'm also curious to know whether I've been in the right ballpark, or even the right state, at any time.
What about lupus?
I'm also curious to know whether I've been in the right ballpark, or even the right state, at any time.
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Strong work to all those brave enough to have a go.
Survey says:
Ok, maybe not the survey, but the experts (aka the senior staff docs here) say...
All of his pathology is likely secondary to Cushing's Syndrome with a very rare (though not unheard of) mechanism.
The stipulated mechanism based on the outlandish lab values is there is some defect in cellular cortisol metabolism which increases its duration of action.
Additional newly synthesized cortisol is shunted to mineralcorticoid (aka aldosterone) Making the glucocorticoid level normal and still developing clinical signs of cushings.
The initial symptoms appearing during his teenage years went either undx or misdx, leading to severe depression, concurrent alcoholism and liver failure.
The depression was probably also not helped by reduced level of sexual characteristics though still functional.
Since the spotty medical care did not come up with a dx, the family attributed it to laziness, further degrading the social support mechanisms.
Long term un dx or uncontrolled HTN from the aldosterone led to the dilated cardiomyopathy, with the SAM reducing the ejection fraction and subsequent arrhythmia and relief upon sitting/squatting.
The pt was discharged today with largely supportive treatment and a rather grim prognosis.
He was disqualified for heart transplant due to preexisting pulmonary HTN.
A pacemaker/defibrillator was implanted mainly for cardiac supportive therapy.
Annular banding of the valves via angio or surgery was not attempted. Septal ablation was not attempted.
The Pt. got his teeth pulled and fitted for dentures.
Pharmacological hormonal and blood pressure control was initiated.
Antidepressant meds and psych follow up.
Family seems very remorseful and will probably be a little more tolerant and I even dare say sympathetic.
Bottom line:
If it looks like a duck and quacks like a duck, it's a duck no matter what the lab numbers are.
No it was not lupus. Sorry.
Survey says:
Ok, maybe not the survey, but the experts (aka the senior staff docs here) say...
All of his pathology is likely secondary to Cushing's Syndrome with a very rare (though not unheard of) mechanism.
The stipulated mechanism based on the outlandish lab values is there is some defect in cellular cortisol metabolism which increases its duration of action.
Additional newly synthesized cortisol is shunted to mineralcorticoid (aka aldosterone) Making the glucocorticoid level normal and still developing clinical signs of cushings.
The initial symptoms appearing during his teenage years went either undx or misdx, leading to severe depression, concurrent alcoholism and liver failure.
The depression was probably also not helped by reduced level of sexual characteristics though still functional.
Since the spotty medical care did not come up with a dx, the family attributed it to laziness, further degrading the social support mechanisms.
Long term un dx or uncontrolled HTN from the aldosterone led to the dilated cardiomyopathy, with the SAM reducing the ejection fraction and subsequent arrhythmia and relief upon sitting/squatting.
The pt was discharged today with largely supportive treatment and a rather grim prognosis.
He was disqualified for heart transplant due to preexisting pulmonary HTN.
A pacemaker/defibrillator was implanted mainly for cardiac supportive therapy.
Annular banding of the valves via angio or surgery was not attempted. Septal ablation was not attempted.
The Pt. got his teeth pulled and fitted for dentures.
Pharmacological hormonal and blood pressure control was initiated.
Antidepressant meds and psych follow up.
Family seems very remorseful and will probably be a little more tolerant and I even dare say sympathetic.
Bottom line:
If it looks like a duck and quacks like a duck, it's a duck no matter what the lab numbers are.
No it was not lupus. Sorry.
Aidey
Community Leader Emeritus
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Well, I was at least in the ballpark.
I thought my explanation of the false normalish cortisol levels was genius though
I thought my explanation of the false normalish cortisol levels was genius though
A very interesting case. I was in way over my head.
Those are my favorite kind actually.
This guy was in the hospital for 21 days while all of this played out. I would say you and Aidey did quite well for less than 72 hours.
Brown was going to say cardiomyopathy or something cardiac; ie dialated myocardium, regurg, syncope etc
Now, orange "DOCTOR" jumpsuits for all!
Same here. I was thinking endocarditis secondary to the dental caries, and some sort of endocrine disorder that I couldn't quite figure out. Interesting case indeed.
Vene, keep them coming! We've all had those pts that we really had no idea what was going on. It's nice to get the full story. The best we can often get is a few differentials from the Attending if they're not too busy. In my experience, hospitals don't generally give EMS any pt info. We are usually limited to the ED staff on that particular day.
Aidey
Community Leader Emeritus
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I was proud I was able to account for all of the signs/symptoms, even if I wasnt right.
What was causing the hypoproteinemia and elevated LFTs? Was that part of the endocrine issue or incidental?
What was causing the hypoproteinemia and elevated LFTs? Was that part of the endocrine issue or incidental?
Poor lupus. Always the bridesmaid, never the bride.
I suppose, having now re-read this thread with the answer in mind, that the fat pad to the upper back is the "hump back" of Cushing's that I should have recognized.
It is usually the bride.
SLE has a predominance in females. (like most autoimmune disorders)
Aidey
Community Leader Emeritus
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Oh, and where did the micro infarcts come from?