Adrenal Insufficiency and Autoimmune Disease

Adrenal insufficiency is a condition where the adrenal glands do not produce enough hormones. In patients with a pre-existing autoimmune disease, such as diabetes, it is most likely that the cause of adrenal insufficiency is autoimmune adrenal failure. This means that the immune system mistakenly attacks the adrenal glands, leading to their dysfunction.

To definitively diagnose adrenal insufficiency, a Synacthen test is performed. This test involves injecting a synthetic hormone called Synacthen, which stimulates the adrenal glands to produce cortisol. Blood samples are taken before and after the injection to measure cortisol levels. If the adrenal glands are functioning properly, cortisol levels will increase after the injection. However, if the adrenal glands are not producing enough cortisol, there will be little to no increase in cortisol levels after the injection, indicating adrenal insufficiency.

Thyroid Cancer and Graves’ Disease

This woman has hyperthyroidism and a cold nodule on uptake scanning, which strongly suggests thyroid carcinoma. The most likely diagnosis is Graves’ disease, which is characterized by periorbital puffiness and a thyroid bruit, and is often associated with papillary thyroid carcinoma. While thyroid cancer associated with Graves’ disease is not uncommon, it is important to consider this possibility in cases of suspicious or expanding nodules, rather than attributing them solely to Graves’ disease. In fact, more than 70% of cases of Graves’ disease are associated with thyroid peroxidase antibodies. Therefore, it is important to carefully evaluate any nodules in patients with Graves’ disease to ensure timely diagnosis and treatment of any potential thyroid cancer.

Gas Gangrene: Diagnosis and Treatment Options

Gas gangrene is a medical emergency caused by Clostridium perfringens infection, which rapidly leads to muscle necrosis, gas production, and sepsis. The most common clinical presentation is post-traumatic gas gangrene, which occurs through direct inoculation of contaminated ischaemic wounds. Immediate management involves resuscitation with oxygen and intravenous fluids to stabilise the patient. The definitive treatment for gas gangrene is surgical debridement.

While certain antibiotics like penicillin are not effective enough treatment alone, hyperbaric oxygen can be used as a supportive treatment. Tetanus toxoid is a vaccine given in childhood for the prevention of tetanus, and in non-immunised individuals with high-risk injuries, tetanus antitoxin may also be administered. Immunoglobulin therapy is used in a wide variety of conditions such as immune-mediated thrombocytopenia and Guillain–Barré syndrome, and may be used as an add-on treatment for severe sepsis.

In conclusion, gas gangrene is a serious condition that requires immediate medical attention. Early diagnosis and prompt treatment with surgical debridement and supportive therapies can improve patient outcomes.

Non-ST-segment elevation myocardial infarction (NSTEMI) requires immediate intervention to reduce cardiac oxygen demand and alleviate ongoing chest pain. In this case, the patient has already received sublingual glyceryl trinitrate (GTN) but still experiences hypertension and chest pain. The following interventions are possible:- IV GTN: GTN acts as a vasodilator, reducing cardiac afterload and improving heart failure symptoms. If sublingual GTN is ineffective, a GTN infusion can be started with strict blood pressure monitoring.- IV Morphine: Morphine acts as a vasodilator and an analgesic, reducing afterload and chest pain. However, IV GTN is more effective and has a shorter half-life for better titration.- IV Beta-Blockade: Beta-blockade reduces cardiac oxygen demand but can worsen acute heart failure and should not be initiated in this setting.- IV Streptokinase: Thrombolysis may be considered in ST-segment elevation myocardial infarction if PCI is not available or delayed. However, this patient has no ST-segment elevation.- PCI: While PCI may be the most appropriate definitive intervention, in this case, a GTN infusion may be required for immediate relief of symptoms.

Chlamydia psittaci is the correct answer as it can cause atypical pneumonia, also known as Psittacosis. The transmission occurs through inhalation of aerosolized faecal and urinary products found on bird feathers. Patients may experience a prodrome of high fevers, diarrhoea, and epistaxis, along with splenomegaly and a low white blood cell count. This organism should be suspected in cases of respiratory infection with the aforementioned symptoms, especially if the patient has been exposed to birds, including parrots.

Klebsiella pneumoniae is an incorrect answer as it typically causes cavitating pneumonia and is not associated with epistaxis, although it is common in individuals who consume excessive amounts of alcohol.

Legionella pneumophilia is also an incorrect answer as it can cause atypical pneumonia and diarrhoea, but the white blood cell count is usually elevated, and epistaxis and splenomegaly are less common. Patients are typically exposed to poorly ventilated air conditioning systems.

Leptospira alexanderi is another incorrect answer as it causes Leptospirosis, which is characterized by jaundice, subconjunctival haemorrhages, and deranged liver function. Although freshwater swimming may expose the patient to this organism, it does not cause atypical pneumonia.

Pneumonia is a common condition that affects the alveoli of the lungs, usually caused by a bacterial infection. Other causes include viral and fungal infections. Streptococcus pneumoniae is the most common organism responsible for pneumonia, accounting for 80% of cases. Haemophilus influenzae is common in patients with COPD, while Staphylococcus aureus often occurs in patients following influenza infection. Mycoplasma pneumoniae and Legionella pneumophilia are atypical pneumonias that present with dry cough and other atypical symptoms. Pneumocystis jiroveci is typically seen in patients with HIV. Idiopathic interstitial pneumonia is a group of non-infective causes of pneumonia.

Patients who develop pneumonia outside of the hospital have community-acquired pneumonia (CAP), while those who develop it within hospitals are said to have hospital-acquired pneumonia. Symptoms of pneumonia include cough, sputum, dyspnoea, chest pain, and fever. Signs of systemic inflammatory response, tachycardia, reduced oxygen saturations, and reduced breath sounds may also be present. Chest x-ray is used to diagnose pneumonia, with consolidation being the classical finding. Blood tests, such as full blood count, urea and electrolytes, and CRP, are also used to check for infection.

Patients with pneumonia require antibiotics to treat the underlying infection and supportive care, such as oxygen therapy and intravenous fluids. Risk stratification is done using a scoring system called CURB-65, which stands for confusion, respiration rate, blood pressure, age, and is used to determine the management of patients with community-acquired pneumonia. Home-based care is recommended for patients with a CRB65 score of 0, while hospital assessment is recommended for all other patients, particularly those with a CRB65 score of 2 or more. The CURB-65 score also correlates with an increased risk of mortality at 30 days.

Behçet’s syndrome is a systemic vasculitis that affects young people from the Middle East, the Mediterranean region, and the Far East. It presents with mucocutaneous, ophthalmological, vascular, gastrointestinal, and central nervous system manifestations. A pathergy reaction is one of the diagnostic criteria. Aseptic meningitis is a possible CNS manifestation. The clinical presentation is typical and is the base for the diagnosis. Azathioprine and other immunosuppressive therapies are used when severe manifestations are present. Other causes of aseptic meningitis include viruses, partially treated bacterial meningitis, fungal meningitis, parasites, drugs, and systemic diseases. The history of flu vaccination is misleading in this scenario. Rheumatoid factor, anti-nuclear antibodies, and anti-neutrophil cytoplasmic antibodies are usually negative in Behçet’s syndrome.

Hypoadrenalism is a common complication in patients with HIV, often caused by necrotising adrenalitis related to cytomegalovirus (CMV). The weakened adaptive immune system in HIV and AIDS patients increases their vulnerability to CMV infection, which in turn increases the risk of adrenal failure.

The first step in managing hypoadrenalism is to quickly replace steroids, while also prioritizing fluid resuscitation.

There is no conclusive evidence to suggest a bacterial infection, and addressing the hypoadrenalism should resolve the hyperkalaemia.

Understanding Addisonian Crisis and Its Management

Addisonian crisis is a medical emergency that occurs when the adrenal glands suddenly stop functioning properly. This can be caused by various factors such as sepsis, surgery, adrenal haemorrhage, or steroid withdrawal. The condition is characterized by symptoms such as severe weakness, low blood pressure, dehydration, and electrolyte imbalances.

To manage Addisonian crisis, immediate medical attention is required. The first step is to administer hydrocortisone, either intravenously or intramuscularly, at a dose of 100 mg. This should be followed by the infusion of normal saline or dextrose if the patient is hypoglycaemic. Hydrocortisone should be continued every 6 hours until the patient is stable. Fludrocortisone is not required as high cortisol levels exert weak mineralocorticoid action.

After 24 hours, oral replacement therapy may begin and gradually reduced to maintenance over 3-4 days. It is important to monitor the patient’s electrolyte levels and blood pressure during this time. With prompt and appropriate management, most patients with Addisonian crisis can recover fully.

Treatment for Cocaine-Induced Symptoms

Cocaine use can lead to various sympathetic effects such as tachycardia, hypertension, anxiety, seizures, and headaches. In case of agitation, seizures, and hypertension, benzodiazepines like midazolam are the initial treatment of choice. Beta blockers should be avoided as they can worsen hypertension by causing unopposed alpha activity. Calcium channel blockers like nifedipine can be used as a second line treatment for hypertension if benzodiazepines are not effective. Clonidine or dexmedetomidine, which are centrally acting alpha-2 agonists, can be used to treat anxiety and hypertension with a single agent. However, labetolol is not recommended as it does not abolish coronary artery spasm. It is important to seek medical attention immediately if any of these symptoms occur after cocaine use.

A patient with a history of long-distance running presents with symptoms of presyncope and relative bradycardia on clinical examination. A normal ECG and CXR suggest a diagnosis of paroxysmal atrial fibrillation related to a runner’s heart. To confirm the diagnosis, a 24-hour cardiac monitor is necessary. An echocardiogram should also be performed to exclude any structural cardiac abnormality. Sinus tachycardia is unlikely due to the resting bradycardia, while atrial and ventricular ectopics may cause short palpitations but not prolonged palpitations or presyncope. Ventricular tachycardia is also unlikely given the patient’s age and fitness level, but should still be investigated with a 24-hour Holter monitor.

When it comes to dosing aminoglycosides, the traditional approach of three times daily (tds) dosing is still used in certain patient groups such as those with burns, ascites, pregnant women, and those with low creatinine clearance. However, for other patients, daily dosing is just as effective with fewer adverse events. In the tds dosing setting, a peak level of 3-4 µg/ml is targeted with a trough level above 2 µg/ml. In serious invasive infections, a greater peak of 6-8 µg/ml may be targeted.

Moving to twice-daily (bd) dosing is not preferred in burns patients as it can increase variance in plasma levels of gentamicin, potentially leading to reduced coverage against bacterial pathogens and increased toxicity. Increasing the gentamicin dose to 80 mg tds can result in possible toxicity, while reducing the dose to 40 mg tds can lead to inadequate coverage against bacterial infection.

When assessing gentamicin dosing, it is important to consider both the predose (trough) level and peak level. If the trough level is raised, the interval between doses should be increased, but if the peak concentration is raised, the dose should be decreased. If the trough dose is within the normal limits, the dosing interval should be kept the same.