CASE 6: Not Sepsis

 

34 year male brought in by ambulance feeling unwell. He had had a recent history (of about 48hrs) suggestive of upper respiratory tract infection (URTI) – runny nose, productive cough, sore throat etc. However, in the last 12 hours or so she had started to feel much more unwell. He felt more washed out and lightheaded, developed nausea and had vomited once or twice. He also felt that there was a slight increase in the cough.

He complained of a mild headache. He denied urinary symptoms although said the urine was darker than normal. There was no chest or abdominal pain or loose stool.He denied rashes, photophobia or neck stiffness.

Past Medical History:   Well controlled Crohn’s disease – didn’t feel like a flare

Drug History:      Budesonide 3mg TDS,  NKDA

Social History:       Independent. Lives with partner. Accountant. A non-smoker.

Examination

He looked unwell, was mildly shocked – BP 89/53 and HR 118. Currently afebrile.

A – Patent

B – Talking in full sentences. Sp02 100% (15L NRBM). RR 23. A few crackles LEFT base. Calves SNT. No chest wall tenderness.

C – HR 118. BP 89/53. Heart sounds normal. Warm peripheries.

D – GCS 15/15. No facial weakness. No limb weakness. Making co-ordinated movements. No photophobia. Freely moving neck. Kernig’s neg.

E – Temperature 38.1. Abdomen – Not distended. Soft. Mild non-tenderness. No guarding. Bowel sounds normal. No rashes.

ENT – Mildly red throat. Normal voice. Mildly red ears. No lymphadenopathy

Differential Diagnosis

Diagnosis Rationale
Left lower zone pneumonia Crackles LEFT base

productive cough and SOB

fever

recent URTI type infection

CXR suggestive

Bloods suggestive: raised WCC and CRP

Viral infection Coryzal symptoms – lethargy, fever, sore throat, runny nose etc

intermittently productive cough

Unlikely to cause patient to be quite so unwell

Sepsis Ticked loads of boxes for sepsis:

Mildly raised respiratory rate

Tachycardic

Low blood pressure

Potential source: pneumonia

Raised lactate

 

Adrenal insufficiency (secondary) On longterm steroids

New stress/illness

Ticked loads of boxes for this:

Hypoglycaemia

Hyponatraemia

Hypotension

Mild metabolic acidosis

 

 

Investigations

Venous blood gas:

Lactate 3.4

Gluc 3.9

pH 7.30 – mild metabolic acidosis

Slightly abnormal electrolytes.

Chest x-ray: slight increased lung markings LEFT base

Bloods –           Wcc 13 (neutrophils 10, lymphocytes 8)

CRP 90

K 3.4

Na 131

Creat and Urea normal

Gluc 3.9

ECG: Sinus tachycardia rate 120bpm

Urinalysis: NAD

Diagnosis: Adrenal crisis

Treated for chest sepsis initially. Followed sepsis assessment and management bundles which included:

Fluid

Oxygen

IV antibiotics

The patient then was then treated for adrenal crisis secondary to long term corticosteroid use and new illness. It turned out he had been on budesonide for her Crohn’s for the last 3 months. He was given: Hydrocortisone 200mg IV.

Pathophysiology

The adrenal glands are important endocrine glands they produce cortisol which is released during times of stress to help with immune function, vascular tone and metabolism.

Cortisol release is controlled by the hypothalmic-pituitary-adrenal axis and any disruption to this can lead to adrenal insufficiency.

Causes can be either primary or secondary:

Primary causes are due to direct disease of the adrenals and the most common cause is Addison’s but can also result from trauma, drugs, infections, infiltrative disorders, and genetic disease.

Secondary causes occurs with sudden termination of prolonged glucocorticoid therapy and pituitary disease including brain tumours, medication, necrosis or bleeding, infectious disease, and infiltrative disorders.

When the body is under stress the low cortisol levels are quickly depleted, and the body is unable to mount an appropriate response resulting in an adrenal crisis. The stress can be caused by infection, surgery, trauma, and has even been shown to occur after strenuous exercise or emotional stress

Useful links

BNF advice on steroids and adrenal crisis

Adrenal insufficiency 

 

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