Case 1

Out Of Context

A male patient, 60 years old, known to have chronic renal failure and on regular dialysis, he also has ischemic heart disease and dilated cardiomyopathy.

Two months ago he presented with bilateral pleural and pericardial effusion without tamponade that improved with rearrangement of dialysis and was discharged. He was in an accepted condition up to 3 days ago when he was re-admitted in the ICU in a shock state with failure of all lines of treatment including high therapeutic doses of inotropic agents to correct the shock. How can you think of this situation?

I treated this case as to have adrenal hypo-function with corticosteroids and mineralocorticoids administered over days with a good response as regard blood pressure maintenance which was resistant to treatment with other methods. So the defect here was, in part, of the hormonal control of blood pressure. But this is not the usual context of adrenal hypofunction as we used to know. For example, there is not a previous history of corticosteroids administration with rapid withdrawal neither present a systemic illness or any of the common infections that are known to affect the adrenal gland.