FMOE: The Apathetic Adrenal

4-yo female, african-american with big bushy pigtails and a vacant stare, presented to an outside hospital today after mom noticed that she was unresponsive. Initial exam notable for altered mental status, hypothermia to 35.2, decreased respirations, bradycardia. Her blood sugar was urecordable; she got glucagon IM by EMS, then more glucagon in the ED, then D25, then a dose of 20 mg hydrocortisone with subsequent return to baseline.

Mom is present with the child and notable for flat affect and a poor recollection of when she was seen last, by whom, or the name of any of the specialists that take care of her. She knows her PMD who is an NP at a free clinic.

Her past medical history is notable for a stroke at the age of 3 with persistent right lower extremity weakness and some speech delay, adrenal insufficiency of unknown etiology, and multiple seizure episodes accompanied by hypoglycemia.

The differential for shock that presents as above includes adrenal crisis but also sepsis and dehydration. The prodrome, if history is obtained, may often include a recent illness. This girl, g-tube dependent from her stroke, had vomited twice over the last two days and had generally been 'tired'. Check.

Physical exam findings may support CAH--abnormal genitalia, vitiglio, or the like, which I've never seen. She had no such findings.

The most interesting part of the case is, first, the appeal of a 'fix-it' intervention for a shocky patient--the hydrocortisone brought her back to baseline relatively quickly--and the oddity of such an apathetic parent and child. Their main question on rounds has been 'when can I go home?' A genogram reveals lots of hypoglycemia and stillbirths in first-degree relatives but mom didn't really care. I mean, I know you are a primary care giver for a sick kid and that can be tough but sheesh.

The other part of it is home management. Like asthma, if a kid with known AI starts to get sick, or get fatigued, parents should give them a stress dose of steroids--2 to 3 times their normal dose of supplemental meds. Mom HAD that at home. Although it's easy to use the retrospectoscope on her, it would've saved her kid a lot of possible harm to just treat early. And she's had a STROKE at the age of FOUR in the past! I would think that would catch her attention.

The other explanation is that she's very aware just tired of residents. That's possible.

Still, good to keep on the differential for a cold, slow, shocky kid, especially with a non-specific, malaise-and-angst-laden prodrome or some flu-like illness.

Photo Credit.

No comments: