A 19-year-old female was on a hiking trip with her friends who brought her to the emergency room with lethargy. The only significant medical history she mentions is that she has diabetes and problems with her thyroid. Other than hypotension, the rest of her physical examination is unrevealing.
Which of the following clinical profiles is MOST consistent with a diagnosis of adrenal insufficiency in this patient?
A. Hypotension that is responsive to fluid resuscitationCorrect Answer: C
Patients with type 2 polyendocrine syndrome could present with type 1 diabetes, thyroid autoimmunity, and adrenal insufficiency. Hyponatremia and hyperkalemia are commonly seen in patients with adrenal insufficiency due to diminished cortisol and aldosterone production.
Aldosterone enhances sodium reabsorption and increases urinary potassium secretion. The hyperkalemia that is seen in adrenal insufficiency is largely related to the aldosterone deficiency. Cortisol has a direct suppressive effect on antidiuretic hormone (ADH) secretion, and a deficiency of cortisol results in hyponatremia due to the effect of increased ADH.
Treatment of hyponatremia in adrenal insufficiency requires cortisol and volume repletion. The administration of saline alone is relatively ineffective as the water retention due to ADH persists if cortisol is not supplemented. Cortisol replacement with hydrocortisone helps with the potassium excretion through its mineralocorticoid activity. Hypoaldosteronism should be considered in patients with persistent hyperkalemia accompanied by hyponatremia.
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