View source for WBR0269

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|MainCategory=Community Medical Health Center, Primary Care Office, Inpatient Facilities
|SubCategory=Endocrine, Infectious Disease
|Prompt=A 46 year old alcoholic male is being treated for tuberculosis, but he has not been compliant with his medications.  He comes to his physicians office and complains of increasing weakness, fatigue and febrile episodes on and off over the past one week.  He appears to have lost weight.  His temperature is 99.6 F (35.6 C), pulse is 96/minute and blood pressure is 80/50 mmHg.  There are some pigmentation over the elbows. Cardiac exam is normal.  There is a possibility that he has developed a multi drug resistant strain of tuberculosis.  The next best step in evaluation of the patients low blood pressure will be 
|Explanation=This patient’s hypotension along with symptoms of weakness, fatigue, and weight loss in combination extensor hyperpigmentation are all consistent with [[Addisons disease]].  [[Tuberculosis]] can involve the adrenal glands as an extra pulmonary manifestation and result in [[adrenal insufficiency]].  Measurement of serum cortisol baseline and then stimulation with ACTH will confirm the clinical suspicion.  Cortisol response is measured after cosyntropin is given intramuscularly or intravenously.  The [[ACTH stimulation test]] is used to determine the adrenal reserve capacity for steroid production. 

'''Educational Objective:'''
A known tuberculosis patient with hypotension and symptoms of weakness, fatigue, and weight loss in combination with extensor hyperpigmentation are all consistent with Addison’s disease (adrenal insufficiency) due to extra pulmonary tuberculosis destruction of the adrenal glands.  Measurement of serum cortisol baseline and then stimulation with ACTH will confirm the clinical suspicion.   
|AnswerA=Sputum cultures for mycobacterium tuberculosis


|AnswerAExp='''Incorrect'''-Since the patient was not compliant with his medications, there is a possibility for [[multi-drug-resistant tuberculosis]] in this patient that can be confirmed with sputum cultures.  But  multi drug resistant tuberculosis diagnosis will not direct towards the cause of hypotension in this patient. 
|AnswerB=Drug susceptibility testing
|AnswerBExp='''Incorrect'''-A drug susceptibility testing is only a reliable lab test done before initiating treatment for the multi drug resistant strain.  It is not useful in diagnosing the cause of hypotension in this patient.
|AnswerC=Early morning serum cortisol and cosyntropin stimulation
|AnswerCExp='''Correct'''-This patient’s hypotension along with symptoms of weakness, fatigue, and weight loss in combination extensor hyperpigmentation are all consistent with Addisons disease.  Tuberculosis can involve the adrenal glands as an extra pulmonary manifestation and result in adrenal insufficiency.  Measurement of serum cortisol baseline and then stimulation with ACTH will confirm the clinical suspicion.  Cortisol response is measured after cosyntropin is given intramuscularly or intravenously.  The ACTH stimulation test is used to determine the adrenal reserve capacity for steroid production. 

|AnswerD=Blood culture
|AnswerDExp='''Incorrect'''-Blood culture is not useful as the patients temperature is normal and septic shock is not suspected.
|AnswerE=Chest X ray
|AnswerEExp='''Incorrect'''-Chest X ray will be useful to diagnose only [[miliary tuberculosis]], a pulmonary complication of disseminated tuberculosis.
|RightAnswer=C
|Approved=Yes
}}