70 yo F with 6 weeks of fatigue and weakness

Original case by Brandon Fainstad, MD. 
Edits and graphics by Yilin Zhang, MD.


OBJECTIVES:

  • Evaluate a patient with fatigue

CASE:

A 70 year old woman with relapsed melanoma s/p repeat excision, nodal dissection, XRT and ipilimumab presents with fatigue. All treatment was stopped 5 mos ago for immunotherapy related rash and hepatitis. Her medication reaction was treated with steroids which were tapered off 2 mos ago. For the past 6 wks she has had progressive fatigue, chills, decreased appetite, nausea, vomiting and a 20 lb weight loss.

For the past week she has been unable to climb stairs due to knee pain and fatigue.  Her family describes intermittent episodes of extreme drowsiness and unresponsiveness over the past two days, that self resolve after 20-30min.  During her most recent episode of unresponsiveness her whole body was shaking, but no incontinence or oral trauma during it.  She denies fevers, cough, SOB, chest pain, dysphagia, abdominal pain, dysuria, skin changes or constipation.  Of note, she had been very active up until 6 mos ago, doing gymnastics, including cartwheels and handsprings. In addition to her melanoma history she has hypertension, osteoarthritis in her knees and is currently taking labetalol and MS Contin. She denies any recent travel, EtOH or illicit drug use.

On exam

36.4C, HR 90, BP 160/80, SaO2 94% on RA, BMI 29
She is in no acute distress. She does not have thyromegaly or thyroid nodules. Cardiopulmonary exams are unremarkable. She has R>L knee crepitus with flexion/extension but no redness/warmth or effusion. She has no rashes, surgical scars are clean and dry.

Labs
  • Na 137, K 3.6, Cl 102, CO2 21, BUN 11, Cr 0.8, Glu 52
  • Ca 10.1
  • WBC 9k, Hct 33, Plt 240
  • LFTs nml

What is your diffential diagnosis?

What work-up would you want?


FINAL DIAGNOSIS:


What is the pathophysiology of this diagnosis?

How is it diagnosed?

How is it treated?


TAKE HOME POINTS: 


ADDITIONAL LEARNING:

What are some causes of adrenal insufficiency? 


REFERENCES:

  1. Min, Le, Anand Vaidya, and Carolyn Becker. “Association of Ipilimumab Therapy for Advanced Melanoma with Secondary Adrenal Insufficiency: A Case Series.” Endocrine Practice 18.3 (2012): 351-55.
  2. Bancos, I et al. Diagnosis and management of adrenal insufficiency. Lancet Diabetes and Endocrinology. 2015; 3: 216-26.
  3. Charmandari, E, Nicolaides, NC & Chrousos, GP. Adrenal Insufficiency. Lancet. 2014; 383: 2152-67.

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