A Case of Hyperpigmentation and Hypotension—finding a Unifying Diagnosis

1St. Vincent Charity Medical Center, Cleveland, OH
2Cleveland Clinic Foundation, Cleveland, OH

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 389

Case Presentation:

A 65‐year‐old African American man patient had a 2‐month history of generalized weakness, loss of appetite, loss of weight, and dizziness. He required hospitalization 6 weeks earlier because of hypotension, hyponatremia, hyperkalemia, and dehydration. The patient is a smoker and known to have hypertension, old stroke, and chronic atrial fibrillation (AF) on warfarin. Per physical examination, the patient was hypotensive (blood pressure 72/68 mm Hg) and had a heart rate of 105/minute with irregular rhythm and hyperpigmented gums, lips, and skin creases in his palms. The rest of the exam was unremarkable. Laboratory values showed mild anemia (hemoglobin 11.6 g/dL), INR 6.9, PTT 59.9 seconds, Na 135 mmol/L, K 4.6 mmol/L. Electrocardiogram showed atrial fibrillation (AF) with low‐voltage QRS complexes. Echocardiography revealed loculated space of undetermined origin posterior to the left ventricle without tamponade. Thus, a CT chest was performed that demonstrated multiple small metastatic nodules in the lung parenchyma bilaterally and extensive metastasis in the liver with ascites surrounding the liver, which likely explained the shadow visualized by echocardiography. Liver biopsy confirmed poorly differentiated adenocarcinoma of undetermined origin. Although CA 19‐9 level was elevated, the CT abdomen failed to demonstrate any primary tumors (but both adrenal glands were enlarged). Despite aggressive volume repletion, the patient remained hypotensive and symptomatic. Primary adrenal insufficiency was suspected; adrenocorticotropic hormone was elevated, and the cosyntropin stimulation test confirmed the diagnosis. His hypotension responded to hydrocortisone and fludrocortisone treatment, and the patient became asymptomatic. No further testing and therapy were directed to the primary occult malignancy. The malignancy was considered advanced, and hospice management was initiated. The patient died a few months later.

Hyperpigmentated palms, skin creases, lips, and lower gum.

CT chest showing metastatic nodules in lungs and liver, bilateral pleural effusion, and ascites.

Discussion:

Clinically evident primary adrenal insufficiency (Addison's disease) produced by metastatic carcinoma is rare, despite the frequency of carcinomatous metastases to the adrenal glands. Only 20% of patients with adrenal metastasis are subclinical and have a subnormal cortisol response to ACTH. This is because most of the adrenal cortex must be destroyed before hypofunction becomes evident. Signs and symptoms include hyperpigmentation and persistent hypotension, along with hyponatremia and hyperkalemia. We report this case of Addison's disease as a rare presenting feature for an occult malignancy and emphasize that early recognition of adrenal insufficiency symptoms is critical and may mistakenly be attributed to cancer, especially at early stages. Appropriate hormonal therapy may significantly improve symptoms and quality of life in those patients.

Conclusions:

This case is unique in that metastatic adrenal insufficiency is a relatively rare phenomenon, and we should suspect this when metastatic cancer presents with persistent hypotension, hyperpigmentation, and electrolyte disturbances.

Disclosures:

K. Shaheen ‐ none; M. C. Alraies ‐ none; K. Alokla ‐ none; M. Baibars ‐ none

To cite this abstract:

Shaheen K, Alraies M, Alokla K, Baibars M. A Case of Hyperpigmentation and Hypotension—finding a Unifying Diagnosis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 389. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-hyperpigmentation-and-hypotensionfinding-a-unifying-diagnosis/. Accessed March 20, 2019.

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