A 23-year-old African American female with type 1 diabetes mellitus comes to the office because of recurrent hypoglycemic episodes, which are distributed evenly throughout the daytime. She has had diabetes for the past six years, and has been on a stable dose of insulin. She had a 4-lb weight loss over a period of three months. She has marked loss of appetite, and feels fatigued. She denies any changes in her activity level. She also denies constipation, diarrhea, urinary complaints, cough, shortness of breath, and fever. She did not have her menstrual period for the past three months. She is a college student who lives with a female roommate, and is not sexually active. She denies smoking, drinking, or the use of recreational drugs. She denies any sick contacts or foreign travel. Her family history is unremarkable. On physical examination, she is 5'5" (163 cm) tall and weighs 120 lbs (54 kg). Her blood pressure is 90/60 mm Hg, and her heart rate is 100/min. She did not have skin rashes. Pigmentation was hard to discern. Other systems were normal. Laboratory results are shown below: The EKG and urinalysis results are unremarkable. What is the most appropriate course of action in the management of this patient?

Question

A 23-year-old African American female with type 1 diabetes mellitus comes to the office because of recurrent hypoglycemic episodes, which are distributed evenly throughout the daytime.  She has had diabetes for the past six years, and has been on a stable dose of insulin.  She had a 4-lb weight loss over a period of three months.  She has marked loss of appetite, and feels fatigued.  She denies any changes in her activity level.  She also denies constipation, diarrhea, urinary complaints, cough, shortness of breath, and fever.  She did not have her menstrual period for the past three months.  She is a college student who lives with a female roommate, and is not sexually active.  She denies smoking, drinking, or the use of recreational drugs.  She denies any sick contacts or foreign travel.  Her family history is unremarkable.  On physical examination, she is 5'5" (163 cm) tall and weighs 120 lbs (54 kg).  Her blood pressure is 90/60 mm Hg, and her heart rate is 100/min.  She did not have skin rashes.  Pigmentation was hard to discern.  Other systems were normal. Laboratory results are shown below:  The EKG and urinalysis results are unremarkable.  What is the most appropriate course of action in the management of this patient?

Quizplus · Accepted Answer

Explanation: Patients with one autoimmune disease are predisposed to get other autoimmune diseases. Multiple endocrine glands can be involved in autoimmune polyglandular failure. This patient has type 1 diabetes, which has an autoimmune etiology; she is thus predisposed to get thyroid dysfunction, adrenal failure, primary hypogonadism, atrophic gastritis, and celiac disease, to name a few. The most likely reason for the decreasing insulin requirement in this patient is adrenal failure, for which the cosyntropin stimulation test is indicated. Other clues in this case which lead to the diagnosis of adrenal failure include weight loss, asthenia, eosinophilia, borderline sodium levels, hyperkalemia, mild anion gap acidosis, prerenal azotemia, and low blood glucose levels. The absence of menstruation for the past three months could be due to weight loss and systemic illness, leading to functional hypothalamic amenorrhea; however, autoimmune ovarian failure should also be ruled out by checking FSH and estradiol levels. (Choice A) Decreasing the insulin dose will only be of temporary benefit. A diagnosis of adrenocortical failure is crucial because the patient could have a life-threatening adrenal crisis. (Choice B)Hemochromatosis can cause diabetes, but it is uncommon in young females. (Choice C)There are no clinical features to suggest systemic lupus erythematosus; checking anti-nuclear antibodies is not likely to help in the management of this patient. (Choice D)The patient has normal TSH levels. Checking the free thyroid hormone levels is not required. Educational Objective: Understand that patients with type-1 diabetes mellitus are predisposed to get other autoimmune disorders such as Addison's disease, hypothyroidism, pernicious anemia, etc.

A 23-Year-Old African American Female with Type 1 Diabetes Mellitus