A 46 year old woman was found unresponsive and brought to the ED. She had a hist

Question

A 46 year old woman was found unresponsive and brought to the ED. She had a history of hypertension, drug and alcohol abuse and was a heavy smoker. Ten years previously, she had been treated for tuberculosis. She had a cavitary lung lesion and was treated with 4-drug therapy (isoniazid, rifampin, ethambutol, and pyrazinamide). Initial lab tests revealed the following:

Additional results revealed:

In spite of aggressive measures, the patient never regained consciousness and expired on the second day after admission.

An autopsy was performed with the following findings: The adrenal glands were enlarged (6 x 5 x 2 cm) bilaterally, with a thick, nodular cortex and a firm yellow-tan cut surface and focal calcification was evident in both glands. The right lobe of the liver contained a 2-cm subcapsular nodule beneath the diaphragmatic surface and extensive fibrous adhesions connected the right lobe of the liver to the overlying diaphragm. A 1-cm calcified peritoneal nodule was found in the pelvis. Microscopically, the adrenal glands were nearly completely destroyed by granulomatous inflammation with caseating necrosis. Only a few small nests of adrenal cortical cells remained in the right adrenal gland. Microscopic examination of the liver and peritoneal nodules revealed that these nodules were granulomas. Stains of these tissues for acid-fast bacilli (AFB stain) and for fungi [gomori methenamine silver (GMS) stain] were performed.

Patient Reference Range Sodium 128 136-145 mEq/L Potassium 5.3 3.5-5.1 mEq/L Chloride 88 98-107 mEq/L CO2 10 22-28 mEq/L Glucose 49 74-100 mg/dL BUN 43 6-20 mg/dL Creatinine 2.6 0.9-1.3 mg/dL Calcium 9.2 8.6-10.2 mg/dL

Explanation / Answer

The granulomatous deposits indicate the presence of disseminated tuberculosis. She had a very low sodium and high creatinine which can contribute to her compromised state.

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