Endocrine Abstracts

We present a case of a 26 years old female who was rushed to hospital with 4 days history of abdominal pain, vomiting and dizziness. She also had one episode of diarrhoea. Further history revealed that she had lost 32 kilograms of weight over the last 18 months through diet and exercise. There were no signs suggestive of an eating disorder.

On examination she was peripherally cold, tachycardic (117/min), hypotensive (86/50 mmHg) and sweaty. Her Glasgow Coma Scale was 15. Her chest was clear and she had mild epigastric tenderness. She was fluid resuscitated with 0.9% sodium chloride. Blood test results: pH 7.01, pCO2 (3.2), pO2 (14.6), blood glucose (2.1 mmol/l), HCO3 (12), Na (126), K (5.6), ketones (7.6 mmol/l), urea 15.1 mmol/l and creatinine (79) and CRP (76). 10% Dextrose infusion was started. An adrenal crisis was suspected and she was commenced on IV hydrocortisone. A possible trigger was thought to be gastroenteritis. Her serum cortisol was 13 mmol/l, no baseline ACTH was checked. She remained hypotensive despite aggressive fluids and was subsequently transferred to ITU. Over the next 24 hours her blood pressure was maintained on inotropes however her acidosis was refractory to treatment (pH<7.2 after 8 hours). She was started on sodium bicarbonate 1.26%; however, the effect was not sustained as her pH continued to drop. Her ketones also remained high (5–6 mmol/l) despite a normal glucose (4–7 mmol/l). She was subsequently commenced on 5%Dextrose infusion to halt ketogenesis. Her HbA1c was 35 mmol/mol. Following 5% Dextrose infusions, her acidosis started to improve with normalisation of ketones. Learning points:

1. Adrenal crisis should be treated promptly

2. Euglycaemic or hypoglycemic ketosis can complicate prolonged starvation, vomiting and eating disorders, so detailed and collateral history is important

3. Although very rare, type 1 diabetes can be masked by adrenal insufficiency and present with euglycemic ketoacidosis. It should be considered in similar scenarios.