Fever, hypotension, hypovolemia, gastrointestinal complaints, urinary tract infection.

2. What is the differential diagnosis?

Urosepsis, gastroenteritis, other intra abdominal infections, acute adrenal insufficiency precipitated by an infection.

3. Patient's husband gives a history that she had a tumor removed from the head 2 years ago and has been on multiple hormone replacement medicines since then, none of which have been taken for the past 3 days because of nausea. What may be the diagnosis now?

• Acute adrenal insufficiency exacerbated by bacterial infection in a patient with secondary adrenal insufficiency following the cure of Cushing's syndrome (patient in Case 1). 
• This occurred due to lack of education regarding the need to increase steroids for stress.
•  If this was a patient with no previous history, a rapid ACTH stimulation test should have been done for diagnosis of adrenal insufficiency.
  
  

4. How do you differentiate between primary and secondary insufficiency of this target gland?

5. What therapeutic strategy would you recommend?

a) Now

• -I/V fluids, antibiotics, supportive care
• -Intravenous infusion or I/M hydrocortisone 200-300 mg/24 hours to be tapered down as stress resolves.

b) Long term

• Replacement doses of glucocorticoid (cortisone acetate 37.5 mg/day or hydrocortisone 30 mg/day or prednisone 7.5 mg/day).
• Patients with primary adrenal insufficiency will also require mineralocorticoid e.g., fludrocortisone 100 mcg/day
• Double the dose for minor stress (fever > 100ºF, vomiting, diarrhea, dental procedures, locat anesthesia).
• 10x usual dose for major stress (surgery, major trauma, infection, etc.).
• Parenteral steroids if patient not eating.
• Medic Alert bracelet/chain.
• Regular physician follow up.