A 31 year-old white woman veterinarian presented with a chief complaint of "I think I have leptospirosis" obtained via an occupational exposure. She had worked with a leptospirosis-infected animal about 11 months prior to admission, and thought that she had contracted the illness either then, or from a newly infected animal. She had a recent visit to the emergency department 12 days prior to admission for nausea and vomiting and what was thought to be a UTI with concomitant intravascular volume depletion and hypotension. Systolic blood pressure was 80mmHg. During that visit, she received IV ciprofloxacin and 4L of normal saline. The patient felt better and returned to work the next day, but started to have malaise, vomiting, and dizziness. She left work early, returned home, and called her physician, who advised to her to go the hospital. On further questioning, she reported a 6-12 month history of being thirsty, having intermittent episodes of hypoglycemia (for which her blood sugar was checked at her workplace), decreased libido (attributed to the stress of finishing her veterinary residency), preference for salty foods, having concentrated urine, and markedly increasing skin pigmentation (with only minimal sun exposure). She reported no sick contacts, recent travel, nor recent immunizations, and had no changes in her daily routine. On exam she was found to be in mild distress, nauseated, and had a non-bilious, non-bloody episode of emesis. Her blood pressure was SOrnmHg systolic, and she responded only transiently to fluid resuscitation. Her skin showed bronze pigmentation with extensive freckling and her buccal mucosa and gingiva had patches of dark pigment. The patient underwent a high-dose ACTH-stimulation test and was found to have a minimal cortisol response (no level exceeding 2.5ug/dL). A work up for leptospirosis was negative and a diagnosis of primary adrenal insufficiency was made. After receiving hydrocortisone and fludricortisone, her blood pressures stabilized and her symptoms resolved. She was discharged with endocrinology follow-up care.
Addison's disease affects approximately 8,800 people per million in the US. Unrecognized adrenal insufficiency can lead to shock and even death in times of physiologic stress. We present a case of previously undiagnosed primary adrenal insufficiency in a patient with concern for a diagnosis of leptispirosis, a febrile infections disease usually of the tropics. Leptospirosis can cause both renal and hepatic dysfunction as well as hypovolemia, nausea, vomiting, muscle aches and others, some of which may mimic adrenal insufficiency.
ANDREW M. FREEMAN, MD, AND JAMES SULLIVAN, MD
RHODE ISLAND AND THE MIRIAM HOSPITAL/BROWN UNIVERSITY SCHOOL OF MEDICINE
Copyright Rhode Island Medical Society Dec 2004
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