Case. 66 year old female presents to the ED with a 5/7 hx of feeling
generally unwell with URTI.
Becomes much more unwell over previous 4 hours.
On arrival
RR- 32
P- 160 (SR)
BP - 80/60
Confused
Cap refill 5 secs
CXR - some Right upper lobe shadowing suggesting infection (but not that
much)
BM - 5.4
No initial response to 2 litres IV Saline. Noted to have Rheumatoid
Arthritis and to be on oral prednisolone for this. Given 200mg IV
Hydrocortisone. Dramatic improvement within 10 mins (P-110, BP 120/85,
mental state normalising). Presumed Addisonian component to illness.
It is commonly taught in other illnesses(asthma, anaphylaxis etc.) that the
action of steroids takes >4 hours as the actions are mediated by
intracellular messengers, dna transcription etc.
Question: Is there another mechanism to explain the rapid effect seen in
addisonian crisis (and if so what?) - or was the effect in this lady likely
to be a co-incidental one.
Simon
Simon Carley
SpR in Emergency Medicine
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Evidence based emergency medicine
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