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Differential diagnosis - a crucial factor for the right treatment of the patient. A case report

Stela Petrova, Elena Harizanova, Pavlina Boikova, Radina Dimitrova, Mira Siderova


Introduction: Primary adrenocortical insufficiency is characterized by the loss of glucocorticoid, mineralcorticoid, adrenal and androgen secretion. It frequently manifests with nonspecific com­plaints- fatigue, myalgia, weight loss, hypotension, abdominal pain, nausea, vomiting, hyponatrie­mia, hyperkaliemia. The most serious complication is acute adrenal failure (Addison`s crisis) with a worsening of the symptoms and can be a diagnostic problem as it mimics other diseases and emer­gency states.

Materials and methods: We present a case of 57-year-old man who was admitted as an emergency pa­tient to the clinic of Gastroenterology in Saint Marina`s University hospital, Varna with diarrhea, se­vere hypotension, fatigue, weight loss, loss of appetite, oliguria and melanodermia. In addition to that the standard laboratory blood testing showed anemia and severe hyperkaliemia. Initial work­ing diagnosis of tumor process was considered and a number of tests among which laboratory tumor markers (CEA, CA19-9, PSA) and ultrasound of abdomen were performed. Marker levels were with­in normal range and the ultrasound examination showed no abnormalities. A differential diagnosis of endocrine pathological process was considered and a consultation with the clinic of Endocrinolo­gy was made. The patient was transferred to the clinic of Endocrinology. Laboratory testing for adre­nal function was performed.

Results: The measured values were low for cortisol 8a.m.- 33nmol/L and dehydroepiandrosterone (DHEA-S) - 0.725 and high for adrenocorticotropic hormone (ACTH) - 1016pg/ml. Thus the final diagnosis was primary adrenal insufficiency with acute adrenal failure. An adequate treatment was started immediately and the patient`s state was severely improved.

Conclusion: The clinical manifestation of any given disease could be nonspecific and quite confusing for the physician. Considering all the possibilities as differential diagnosis is crucial for making the right diagnosis and applying adequate treatment.



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