|Year : 2008 | Volume
| Issue : 1 | Page : 85
Adrenal Insufficiency in a Cancer Patient Presenting as Acute Hypotension During Induction of Anaesthesia
Shilpi Singhal1, Pushplata Gupta2, Arun Agarwal3, Nitin Khuteta4, Anjum Khan5
1 Resident, Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital & Research Centre, J.L.N. Road, Jaipur, India
2 Consultant, Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital & Research Centre, J.L.N. Road, Jaipur, India
3 Consultant & Head, Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital & Research Centre, J.L.N. Road, Jaipur, India
4 Consultant, Department of Internal Medicine, Bhagwan Mahaveer Cancer Hospital & Research Centre, J.L.N. Road, Jaipur, India
5 Consultant Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital & Research Centre, J.L.N. Road, Jaipur, India
|Date of Acceptance||12-Oct-2007|
|Date of Web Publication||19-Mar-2010|
H.No. 419, Mahaveer Nagar-I, Tonk Road, Jaipur-302018
A 54 year-old-male, a case of squamous cell carcinoma of right pyriform fossa, treated with radical radiotherapy & chemotherapy in 2004, presented in January 2007, with difficulty in swallowing. He was diagnosed to have squamous cell carcinoma of upper third of oesophagus & surgery was planned. Patient had history of recurrent blackouts which were attributed to generalized weakness and diarrhoea. During induction, he developed Hypotension & on evaluation, was diagnosed to have primary adrenal insufficiency.
Keywords: Adrenal insufficiency/Addison′s disease, recurrent episodes of syncope, Synacthen test, Malignancy or chronic disease.
|How to cite this article:|
Singhal S, Gupta P, Agarwal A, Khuteta N, Khan A. Adrenal Insufficiency in a Cancer Patient Presenting as Acute Hypotension During Induction of Anaesthesia. Indian J Anaesth 2008;52:85
|How to cite this URL:|
Singhal S, Gupta P, Agarwal A, Khuteta N, Khan A. Adrenal Insufficiency in a Cancer Patient Presenting as Acute Hypotension During Induction of Anaesthesia. Indian J Anaesth [serial online] 2008 [cited 2013 May 24];52:85. Available from: http://www.ijaweb.org/text.asp?2008/52/1/85/60605
| Introduction|| |
Primary hypoadrenalism is a rare condition with an estimated incidence in the developed world of 0.8 cases per 100,000 & prevalence of 4-11 cases per 100,000 population  . It is associated with significant morbidity & mortality but if diagnosed, it can be easily treated  . This case report highlights the importance of evaluating for sub clinical adrenal insufficiency in patients with recurrent episodes of syncope  which are otherwise considered to be due to generalized weakness related to comorbid conditions.
| Case report|| |
A 54-year-old male initially presented to Bhagwan Mahaveer Cancer Hospital & Research Centre, Jaipur in 2003 with complaints of difficulty in swallowing. He was diagnosed to have malignancy of right pyriform fossa with stage T 2 N 1 M 0 . He was treated with radiotherapy and concurrent chemotherapy as per protocol. A year later patient developed radiotherapy induced hypothyroidism and was on thyroxine supplementation in dosage of 100 microgram per day. Patient was euthyroid on presentation. In January 2007 he again presented with difficulty in swallowing solids for last 15 days and on evaluation was diagnosed to have growth in upper1/3 of oesophagus. Biopsy was done which showed squamous cell carcinoma. Total laryngo-pharyngo-oesophagectomy was planned and he was referred for pre-anesthesia check-up (PAC). He had 10 to 12 years history of multiple episodes of dizziness and blackouts which were attributed to diarrhoea & generalized weakness. There was no history of tuberculosis, fungal infection, sarcoidosis & diabetes mellitus  . He had no family history of primary adrenal insufficiency  . His routine biochemistry, CBC, ECG, X-Ray chest (PA view), USG (abdomen), CT scan (abdomen) & anti HIV were normal. There was no history of any drug intake of ketoconazole & rifampicin  .
Patient was ASA grade 2 and was taken up for surgery. Patient was shifted to operation theatre. After securing peripheral line & establishing all monitoring, right subclavian vein was cannulated for central venous access and epidural catheter was inserted in T11-12 epidural space. Epidural test dose  of lidocaine 2% with adrenaline 1:100,000 was given & he was observed for tachycardia, hypotension or motor weakness. Patient was then preloaded with 1000 ml of crystalloid and induction was done with ondansetron, fentanyl, propofol & vecuronium bromide. However his blood pressure dropped from 140/90 to 66/44 mm of Hg (NIBP) and was resuscitated with intravenous fluids & mephentermine and the surgery was deferred. Patient was reversed & shifted to post anaesthesia care unit (PACU). In night he had two asymptomatic episodes of hypotension in PACU which were detected during routine monitoring of vital parameters. In view of history of syncopal attacks, malignancy, hypothyroidism & hypotension soon after induction, he was evaluated for possible adrenal insufficiency. His anti-CMV antibodies, antinuclear antibodies & ACE levels were normal  . ACTH stimulation test was done after administration of 250mcg units of Synacthen (cosynotrophin) IM and S.cortisol levels were measured at 0 and 30 min after ACTH administration. Patient's basal cortisol level was 9.95 mcg.dl 1 with a rise to 16.74 mcg.dl -1 (basal cortisol value of > 15 mcg.dl -1 invariably indicates an intact hypothalamic - pituitary axis. A normal response is defined by a peak plasma cortisol level greater than 19 mcg.dl -1 )  . The response was subnormal & suggested adrenal insufficiency. His serum aldosterone levels were not done due to technical reasons. MRI brain was done to rule out any possibility of brain metastasis and evaluating pituitary fossa. It revealed partial empty sella which appeared to be an incidental finding since there were no features suggesting hypopituitarism  . He was started on hydrocortisone 20mg in morning & 10mg in evening. On day of surgery he was given infusion of hydrocortisone 10 mg.h -1 and the surgery was done uneventfully. The infusion was continued for 24 h post-operatively & then he was started on fludrocortisone 100mcg & hydrocortisone 30 mg daily with gastrojejunostomy feeding tube. He was discharged on hydrocostisone (15 mg in divided doses) & 100 mcg of fludrocortisone daily  and the patient is doing well with no further episode of hypotension till last follow up in March 2007.
| Discussion|| |
Adrenal insufficiency is a hormone deficiency syndrome attributed to primary adrenal disease or caused by a wide variety of pituitary - hypothalamic disorders.
Primary or secondary adrenal insufficiency usually present slowly over a period of time with any of the non-specific symptoms of chronic fatigue, weakness, lethargy, anorexia, weight-loss, postural hypotension, nausea, vomiting and diffuse abdominal pain , . Our patient presented with many of these symptoms but wasn't thought of having Addison's disease since he was a known case of malignancy with post radiation and chemotherapy status. The history of multiple episodes of dizziness and blackouts were always correlated by patient with diarrhoea & thus thought to be due to associated dehydration & generalized weakness.
Since weakness, fatigue, anorexia, nausea, vomiting & diarrhoea are common symptoms, a strong suspicion of Adrenal insufficiency should be made in presence of hypotension or postural hypotension  . The ACTH stimulation test should be done to rule out Adrenal insufficiency, particularly before steroid treatment is begun  . Hyperpigmentation is usually not seen & in our patient it was significant in view of post CT/RT status.
During episodes of intercurrent illness, fever, surgery, dental extraction, the requirements of hydrocortisone are increased & if not supplemented, the patient may develop acute adrenal crisis  . This patient probably developed acute adrenal crisis due to pre- surgical stress immediately on induction which led us to suspect & diagnose adrenal insufficiency in this patient. We tried to rule out all possible causes of primary or secondary Addison's disease. Adrenal metastasis could be a possible explanation but the commonest incidence is with primary being lung  . Adrenal metastasis leading to adrenal insufficiency is uncommon, perhaps because greater than ninety percent of the cortex need to be compromised before symptoms & signs of adrenal insufficiency becomes apparent , . However the exact cause of Addison's disease could not be identified in this patient.
We document this case of adrenal insufficiency to emphasize upon the need of evaluating patients with recurrent episodes of syncope which are otherwise contributed to generalized weakness, depression or comorbid conditions  . Adrenal insufficiency is one such underlying possibility particularly in patients with underlying malignancy or chronic disease & should always be considered in differential diagnosis.
Patients with any chronic medical illness with a history of recurrent syncopes &/or chronic hypotension should always be investigated for possible subclinical hypoadrenalism.
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