Monday, December 17, 2012

The Sleeping Patient

An elderly patient has been admitted to the hospital about three weeks ago. His presentation was remarkable for profuse watery diarrhea and terrible abdominal pain. Diagnosed promptly with C diff he was started on vancomycin PO. Because of worsening abdominal pain, leukocytosis Flagyl IV was added. Patient developed perforated bowel and underwent surgery for hemicolectomy.

Our story begins one week after surgery. The sepsis has resolved, but there is one big issue. He does not wake up. NG delivers feed solution. There is a small mask that fits over the patient's tracheostomy site.

There is minimal spontaneous activity. No nystagmus. Corneal reflex present. He seems to feel pain to prick, however the reaction is minimal. Sensation is intact bilaterally. The neck is supple. There are no rashes.

The medication list does not include any sedative/psychotropic medication.

Brain MRI unremarkable. No evidence of infection. Electrolytes, ABG are WNL. No evidence of infection.

He is about to be referred to palliative/comfort care. 

When I think about the causes of acute encephalopathy, I divide them primarily in things in the brain and things outside the brain. Things in the brain would be stroke, masses, seizures, local autoimmune conditions (lupus, paraneoplastic etc). Outside the brain would be everything else metabolic, infectious, endocrine, autoimmune etc. See I VINDICATE (AIDS)

Reviewed all the workup and there was only one missing lab. Next morning the lab reported that the cortisol was 0.5 (normal 6-10 our laboratory). With emotion I ordered another AM cortisol level the next day along with ACTH and high dose cosyntropin stimulation test. Great there was a lead. The second cortisol was 1 and the stimulation failed to lift it more than 6.

Hydrocortisone IV was initiated at 50 mg q8h. The next morning patient awake, able to recognize his wife. Two days later, I found him sitting in bed reading the newspaper. The hydrocortisone was tapered to physiologic levels.

It is very likely that the hypotension / sepsis affected the adrenal glands and the patient had encephalopathy due to profound adrenal insufficiency.

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