CILINICO-PATHOLOGIC CONFERENCE

We are presented with a case of a 44 year old female who came in with chief complaint of weakness and
low blood preassure .
salient featutres.
Hypertensive, hyperthyroidism
History of slowed speech,poor appetite, constipation and edema 2 months ago
Elevated blood sugar level at 600mg/dl, and hypotension at 70/50 on the day of admission.
Review of system showed patient had weight loss, easy bruisability , nocturia, polyuria and
constipation.
Past medical history was unremarkable.
Family history of diabetes and hypertension
Upon admission patient was conscious coherent but hypotensive with blood pressure of
80/60mmHg with dry mucosa, dry skin ang gr I bipedal edema. There was no other pertinent PE
findings at that time.
At the E.R. Patient was hydrated an was refered to an endocrinologist she was seen with coarse hair,
puffy eyelids thin eyebrows
Upon admission:
Diffential diagnosis are the following:
1. Cushings syndrome was ruled in due to the following
Hypertension; presence of striae
Hyperglycemia


2. Myxedema
Presence of edema, constipation dry mucosa and dry skin
Lethargy and slowed speech
History of use of anti thyroid drugs

3. Malignancy ( Pituitary adenoma)
Weight loss malignancy should always be considered in patient with wt loss.

COURSE IN THE WARDS
On the 2nd HD
The patient was febrile with episodes of dyspnea and desaturation attending physicisians
noted that patient have dark gray material and food particle per NGT, foul smelling vaginal discharge
and crakles on lung auscultation mid to base. Patient also presents with moon face facial plethora
buffalo humps supraclavicular fullness, atropy and weakness of lowe extremities. Potassium correction
was continued and was started on furosemide, omeprazole piperazillin-tazobactam metronidazole and
azithromycin.

On the 3rd HD
Patient had respiratory distress, hypotension , change in sensorium and was intubated
She was then started on dopamine drip, decrease breath sounds and crakles were still present hence
was transferred to ICU.
At the ICU vital signs stabilized still with decreased breath sounds and crakles with
abdominal skin striae serum cortisol was requested and was started on hydrocortisone IV.

On the 4
th
HD
Patient was scheduled for hemodialysis but became hypotensive with BP of 80/60mmHg
and tachycardic with cardiac rate of 117 bpm, hematoma formation on the left knee followed with
decrease sensorium and unappreciable blood pressure but eventually improved with dopamine and
levophed ( nor epinephrine) drip.
On the fifth HD
Still with unstable neurologic status with waxing and waning sensorium ,still with vaginal
discharge, motting of lower extremities.





Circumstances surrounding Death
12 hours before death
Patient BP went as low as 50/30mmHg with endo tracheal tube secretios and no urine output,
furosemide IV was given with standby blood trans fusion. Metronidazole wa shifted to clindamycin.

8 hours before death
still with frothy endotracheal tube secretions and hypotension 50/30mmHg dopamine and levophed
were continued.
2 hours before death
Patient still hypotensive with et tube secressions, coffee ground material was noted per NGT then
patient became comatose with pale conjunctiva and nail bed.s neck veins were noted to be engorged
with hematoma formation on both lower extrimities and cyanosis of both lower extremities. She was
then pronounced dead afterwards.

CAUSE OF DEATH: MULTIPLE ORGAN FAILURE SECONDARY TO
ADRENAL INSUFFICIENCY SECONDARY TO
CUSHINGS SYNDROME SECONDARY TO
MALIGNANCY PROBABLY ( PITUITARY ADENOMA)