Hot Seat #143 Denouement: 12 year-old girl with nausea

Posted on: January 16, 2020, by :

The Case: 12yoF, otherwise healthy, presenting with acute inability to eat in the setting of chronic abdominal pain, nausea, and weight loss, found to be severely hyponatremic.

Here’s how you answered:

Differential Diagnosis in both groups included:

Anorexia, Addison’s Disease, SMA syndrome, Acute gastritis, or Secondary SIADH

Discussion: This is an interesting case that reiterates the importance of anchoring bias in medicine and perhaps what distinguishes the good physician from the great physician. The history lined us up well for a potential adolescent restricting herself into a potential eating disorder. Dr. Chapman, however, reminded us that when we get results of a test that do not match what we expect we should take a step back and think why.

Was it a lab error? Was it a mislabeled specimen? Was in incorrectly handled/drawn? Or indeed is it real and perhaps our differential diagnosis is off.

Nonetheless, the overwhelming majority of respondents as well as the group in discussion wanted an endocrine consult to help ensure us that we may not be missing Addison’s disease (adrenal insufficiency).

Denouement: The patient was admitted to the Adolescent medicine service due to concern for an eating disorder with nephrology consulting. She was started on the eating disorder protocol. Initially, the patient’s sodium improved after a normal saline bolus and sodium chloride supplementation. Her sodium levels then dropped and hyponatremia persisted. Endocrinology was consulted and noted hyperpigmentation of the palmar creases, thus requesting additional testing including an ACTH stimulation test revealed a diagnosis of Addison’s disease. Stress dose steroids were started and marked improvement was noted. Since that time, her nausea and vomiting have resolved and she has gained weight.

Interestingly enough there are case reports for both Addison’s Disease and Cushing’s Syndrome initially presenting as eating disorders. Click here to learn more.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

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