CASE 3

History:
MSJ a 34 years old Malay gentleman with a known history of CCF, HPT for the last 6 months treatment and follow up, gouty arthiritis for the last 6 years not on any mediations and childhood bronchial asthma on MDI salbutamol PRN and MDI bedesonide BD; presented to the ED with sudden vision loss for 4 days prior or admission. Vision loss affected far vision only and was associated to flashes and floaters which suggest a retinal detachment or a diabetic retinal pathology. There was no pain nor redness nor discharge of the eye which could rule out acute angle closure glaucoma, acute uveitis.

Besides that, he complains of a right wrist pain that was throbbing in nature for the past 2 days. It has been increasing in severity and pain was aggravated by movement. The wrist pain is most likely a flare of his gouty arthritis.

He has been very thirsty for the past 2 weeks and have been drinking large volume of water  per day despite been adviced for ROF of less than 1liter. With this he has been also having frequent urination. A symptom of polydipsia, polyuria maybe due to hyperglycaemia.

He needs to sleep at a 45 degree angle to prevent SOB. He is unable to climb stair and keep up with his friends of same age while walking on level ground, NYHA class II. He also complains of massive weight gain for the past 6 months. He admits to not to be complaint to all his medications. However, he further adds that he has been taking traditional medications for his gouty arthiritic flares for the past 6 years. All these symptoms started 6 months ago when he decided to take a stronger traditional medication. There is a suspicion these disease, CCF, hypertension, eye pathology due to hyperglycaemic state due to the steroid content of the traditional medication leading to Cushing's syndrome.

6months ago he was admitted for decompensated CCF secondary to IHD, showing that the heart function may be compromised.

There is strong family history of hypertension and diabetes. Socially he has been a ex smoker for 6 years now but has smoked for 15 pack years previously. Which seems to be risk factors for cardiovascular diseases.


Physical:

On physical examination, his vitals recorded an elevated blood pressure of 159/119mmhg, with borderline tachycardic pulse of 92bpm. Other vitals were normal. 19 breathes / mint and afebrile. He was not on respiratory distress and was seated at a propped up 45 degrees as ay lower would cause him shortness of breathe. RBG: 22.5mmol/L. There is a ver much elevated blood glucose indicating that we might be dealing with a case of diabetic mellitus.

General examination reveled moon facies, acanthosis nigrican over the back, dorsal cervical fat pad, abdominal dissension with purple striae, hyper pigmented lower limbs and bilateral pedal oedema. This corresponds to the suspicion of cushing's syndrome. He was not pale, jaundiced nor dehydrated.

Examination of the eye, showed normal pupillary light reflex, normal visual field, no clouding of the lenses. However, patient could only see near vision up to 3feet. Funduscopy was done but it was hard to visualise the fundus due to the ward lighting condition.  Visual acuity and funduscopy is to be repeated in a controlled setting. Cardiovascular, respiratory, CNS  and abdominal systems were all noted to be normal.

Provisional diagnosis: Complicated exogenous Cushing syndrome with CCF , HPT, diabetes mellitus  and diabetic maculopathy.


Investigation that we ordered was:
FBC : TWC, HB, PLT was normal , which indicates to anaemia, thrombocytopenia  nor ongoing infection that maybe present as a complication to Cushing's.
RP: decreased serum sodium and chloride is likely due to the dehydration.
LFT: increased protein and globulin. ALP(116), GGT (100) was elevated.  This shows some assault to the liver and this may have been caused by the traditional medication.
Chest radiograph: cardiomegaly is due to the CCF.
ABG: no metabolic acidosis. Was normal. in a case of DKA, metabolic acidosis might be expected.
URIC ACID: elevated 628. confirms that the is a flare of the disease currently.


HBa1C and FBG was ordered in view of suspected DM.  FSL, Serum&Urine Cortisol is ordered in view of the suspected Cushing's Syndrome


Management
He was restarted on his old medications which included;
- T Bisoprolol 2.5mg OD, T. Digoxin 0.125mg OD fr the CCF
- T. Perindopril 4mg OD, T. Amlodipine 10mg OD, T. Spironolactione for the hypertension
- T. Simvastatin 40mg ON against dyslipidemia
- T. Cardipin as an anticlotting prophylactic against ACS and CVA
- Isosorbide mononitrate 30mg OD as a prophylaxis against angina pain.

I/O chart was started view of dehydration.
Frusemide 40mg OD was  withheld due to the acute flare of gout.
Metformin withheld due to the history of CCF.
IV drip normal saline 1 pint due to to the increase sodium and chloride level.
IV Insulin infusion was started.
Patient was educated on disease process and harmful effects of traditional medications. Was successful to getting patient to stop intake of traditional medication.
Tramadol was added for patient's gouty flare and allopurinol was to be started.
We are monitoring for hypotension and hypoglycemia which are symptoms of addisonian crisis.


Patient Progress
Day 1:
- Patient has no improvement of yet.

- A proper eye examination in a controls setting was repeated that revealed visual Acuity was 6/45 and 6/12 on pinhole on both sides. Funduscopy revealed optic disc swelling, with nasal deviation which suggest diabetic papilitis. He was then referred to the ophthalmology department that confirmed the diagnosis. A fundus camera also confirmed a mild,  non proliferative diabetic retinopathy. The management that was suggested by the opthal team was for good diabetic control and he was given a 2 months appointment at the eye clinic for further assessment and follow up of his eye condition.

- Today's RBG reduced to 13.2 mmol/L as he has been started on IVI Actraprid with sliding scale.
- BP has reduced to 142//88mmHg after been re-started on his previous medications.
- Investigation that has returned include FSL that was raised (Total cholesterol of 6.5 and TG of 13.9!!) This high reading is most probably attributed to Cushing's syndrome)
- He was also referred to the dietician for a proper diabetic and dyslipidemia intake counselling.

We are treating the patient as Complicated exogenous Cushing syndrome with CCF , HPT, diabetes mellitus  and diabetic maculopathy. The patient was planned for discharged if the glucose level and BP returned to the normal. He would be then taken care as an outpatient.

Day 2:
With the normalised glucose level of 9.9mmol/l and blood pressure of 135/82mmHg, he was planned for discharge and for a follow up at the clinic in 2weeks. The Serum & urinary cortisol and HbA1C was not available as yet and will be reviewed at the clinic. He was discharged  his previous usual medications with a few medication added on, which include:
S/C Actrapid 18unit TDS and S/C insulatard 32U ON, T. Metformin 1b BD, T. Glicazide 100mg BD for the diabetes control.
T. Tramadol 50mg TDS for the wrist pain.

He was also educated on diabetes and its complications and the symptoms and signs of hypoglycaemia. We also made sure the he would not take the traditional medications. A TCA was given in 2months to review all investigations and to see how has his Dm, HPT control has been.