• Users Online: 270
  • Print this page
  • Email this page


 
CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 1  |  Page : 85 Table of Contents     

Adrenal Insufficiency in a Cancer Patient Presenting as Acute Hypotension During Induction of Anaesthesia


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 Acceptance12-Oct-2007
Date of Web Publication19-Mar-2010

Correspondence Address:
Shilpi Singhal
H.No. 419, Mahaveer Nagar-I, Tonk Road, Jaipur-302018
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
 

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 2020 Oct 20];52:85. Available from: https://www.ijaweb.org/text.asp?2008/52/1/85/60605


   Introduction Top


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 [1] . It is associated with significant morbidity & mortality but if diagnosed, it can be easily treated [2] . This case report highlights the importance of evaluating for sub clinical adrenal insufficiency in patients with recurrent episodes of syncope [3] which are otherwise consid­ered to be due to generalized weakness related to comorbid conditions.


   Case report Top


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 [4] . He had no family history of primary adrenal insufficiency [4] . 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 [3] .

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 [5] 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 [4] . 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 ) [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 [4] . 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 [4] and the pa­tient is doing well with no further episode of hypotension till last follow up in March 2007.


   Discussion Top


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 [2],[3] . 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 [6] . The ACTH stimulation test should be done to rule out Adrenal insuf­ficiency, particularly before steroid treatment is begun [4] . 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 [6] . 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 [7] . 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 [2],[4] . 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 [3] . 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.

 
   References Top

1.Stewart PH. The Adrenal Cortex. Chapter14 525-530 in William's Textbook of Endocrinology, 10 th ed. Elsevier India, New Delhi.  Back to cited text no. 1      
2.Wilton A. The Endocrine System. Chapter24 394-395 in Wylie & Churchill-Davidson's A Practice of Anesthesia, 7 th ed. by Thomas E J Healy & Paul R Knight.  Back to cited text no. 2      
3.Williams GH & Dluky RG. Disorders of Adrenal Cortex. Chap­ter321 2142-43 The Harrision's Principles of Internal Medi­cine, 16 th ed.  Back to cited text no. 3      
4.Cooper MS, et al. Current concepts: Corticosteroid Insuffi­ciency in acutely ill patients. New England Journal of Medi­cine 2003;348:727-29.  Back to cited text no. 4      
5.McConachie I, McGeachie J & Barrie J. Regional Anaesthetic Technique. Chapter-37 614 in Wylie & Churchill-Davidson's A Practice of Anaesthesia, 7 th ed. By Thomas E J Healy & Paul R Knight.  Back to cited text no. 5      
6.Bouillon R. Acute Adrenal Insufficiency, Endocrinology and Metabolism Clinics of North America, 2006;35:769-775.  Back to cited text no. 6      
7.Hricak H, Akin O, et al. Advanced Imaging Methods. Chap­ter24 597-599 Devita -Text Book on Medical Oncology.  Back to cited text no. 7      




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Case report
    Discussion
    References

 Article Access Statistics
    Viewed1386    
    Printed74    
    Emailed0    
    PDF Downloaded213    
    Comments [Add]    

Recommend this journal