Rachel has been taking prednisolone for some time as a treatment for her arthrit
ID: 3509868 • Letter: R
Question
Rachel has been taking prednisolone for some time as a treatment for her arthritis, but abruptly stopped because it was making her look “puffy.” Three weeks later she went to a physician because she had difficulty sleeping, was always uncomfortably warm, and generally felt poorly. The physician noticed that she was sweaty and had a rapid pulse and high blood pressure. He also noticed that her eyes seemed to bulge. He said she might have a pheochromocytoma, but needed to test more-likely possibilities. He was surprised that her blood glucose was low, because previously it had tested somewhat high. He said the other results suggested that her symptoms were due to Graves' disease.
Some of the new terms and concepts you will encounter include:
TSH, thyroxine, and Graves' disease
ACTH, corticosteroids, glucocorticoids, and Addison's disease Adrenal medulla, catecholamines, and pheochromocytoma
Rachel abruptly stopped taking prednisolone and measured a low blood glucose level.
What happened to her ACTH secretion while she was taking prednisolone, and how does taking prednisolone relate to her puffy appearance?
What condition did she acquire when she abruptly stopped taking prednisolone?
Rachel's physician said her symptoms might be the result of a pheochromocytoma, but he needed to test for more likely possibilities.
What is a pheochromocytoma, and how might it account for Rachel's symptoms?
Rachel's physician said she previously had somewhat high blood glucose, but now her blood glucose tested low.
How might her blood tests be related to her taking prednisolone?
How might stopping prednisolone abruptly be related to her blood test results?
Rachel's eyes bulged and she had symptoms that the physician said were a result of Graves' disease.
What must be true of her TSH and thyroxine levels to justify this diagnosis? How does the diagnosis relate to her bulging eyes and other symptoms?
Explanation / Answer
1. Prednisolone is a corticosteroids medication thet is used as antiinflammatory agent. It act just like corticosteroids hormone. It decreases ACTH level by Negative Feedback (as body now has more corticosteroids). It causes puffiness of eyes because of water retention which causes periorbital edema (a Mineralocortocoid effect).
2. Acute Adrenal Insufficiency as her body levels of ACTH was low while taking Prednisolone and abrupt stopping it did't gave body time to respond to decreased ACTH level.
3. Pheochromacytoma is tumor of adrenal gland. The symptoms of this disease (ie high blood pressure, sweating and palpation) are similar to acute adrenal insufficiency. In this disease adrenal glands release large ammont of adrenaline and nor adrenaline that leads to given symptoms.
4. Prednisolone causes Hyperglycemia (it is a catabolic hormone) but when it is abruptly stopped then it leads to Hypoglycemia. Blood tests is can also tell about cell count of immune cell (which will be low in her due to steroid therapy).
5. In Grave's disease due to hyper functioning ot thyroid gland (Hyperthyroidism). TSH (thyroid stimulating hormone) levels are low and Thyroxine (T3 and T4) are high (so it supress TSH by negative feedback). Bulging eyeball (exophthalmos) is seen in Grave's disease also (due to deposit of glycosaaminoglycan, fibrous tissue, fat ,water and edema). Grave's disease also presents with sweating and bulging eyeball, hypoglycemia.
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